Every finding on record at Shore Health & Rehab Center

Based on staff interview and clinical record review, the facility staff failed to provide care and services in accordance with professional standards for 2 of 49 residents (Resident #76 and #125), in the survey sample. The findings included: 1. The facility staff failed to transcribe a physician's order as written, resulting in Resident #76 receiving food prior to administration of the Omeprazole. Omeprazole is used to treat certain conditions where there is too much acid in the stomach. It is used to treat gastric and duodenal ulcers, erosive esophagitis, and gastroesophageal reflux disease. (https://www.mayoclinic.org/drugs-supplements/omeprazole-oral-route/description/drg-20066836) Resident #76 was originally admitted to the facility 1/16/23 and readmitted to the facility acute care hospital stay on 6/10/24. The current diagnoses included an upper gastrointestinal bleed/esophageal bleed. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/15/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #76's cognitive abilities for daily decision making were intact. In section GG0115 A/B Functional Limitation in Range of Motion; the resident was coded to have no impairment of bilateral upper extremities (shoulder, elbow, wrist, hand) and bilateral lower extremities (hip, knee, ankle, foot). At section G0170A, the ability to roll from lying on her back to the left and right side and return to lying on back on the bed was coded as requiring partial/moderate assistance. A review of the resident's monthly medication review revealed on 6/26/24 a progress note from the Pharmacist to the facility's staff to see the consultant pharmacist report for noted irregularities and/or recommendations. The Pharmacist recommendation stated the resident receives the Proton Pump Inhibitor (PPI) Pantoprazole Sodium 40 milligrams (mg) twice daily. In the absence of an indication requiring twice daily PPI therapy (nocturnal symptoms, [NAME]-[NAME] syndrome), please change to Omeprazole 20 mg once daily, thirty minutes before food. The Pharmacist rationale for the change read, dosing for PPI more frequently than once daily may increase the risk of adverse effects such as osteoporotic fracture and C. difficile infection. A review of the physician's Order Summary (POS) revealed the following order dated 7/3/24 for Omeprazole capsule, delayed release 20 mg, one capsule orally once a day between 7:00 AM and 10:00 AM. The Omeprazole order failed to include the specified thirty minutes before food and review of administration of the Omeprazole 20 mg from 7/3/24 through 7/26/24 revealed on four days the medication was not administered until 10:52 AM on 7/15/24, 10:57 AM on 7/16/24, 12:14 PM on 7/20/24 and 10:46 AM on 7/21/24. During the survey 7/23/24 through 7/26/24 Resident #76 was observed having the breakfast meal tray removed from her room before 10:00 AM, indicating she received and consumed some of the meal prior to administration of the Omeprazole. On 7/26/24 at approximately 4:45 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), Regional Nurse Consultants and the [NAME] President of Operations. The DON stated the timing of administration of the Omperazole would be adjusted so it will be administered thirty minutes prior to food. The facility staff had no additional comments and voiced no concerns regarding the above information deficient practice. 40711 2.The facility staff failed to administer Doxepin HCL 150 mg capsule to Resident #125 for (3) three nights, according to physicians order. Doxepin is used to treat anxiety or depression. It is also used to treat insomnia (trouble with sleeping). Doxepin is a tricyclic antidepressant (TCA). It works on the central nervous system (CNS) to increase levels of certain chemicals in the brain. This medicine is available only with your doctor's prescription. This product is available in the following dosage forms: Tablet, Capsule, Solution. https://www.mayoclinic.org/drugs-supplements/doxepin-oral-route/side-effects/drg-20072083?p=1 Resident #125 was originally admitted to the facility 1/18/23 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Paranoid Personality Disorder and Bi-Polar Disorder The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/18/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #125 cognitive abilities for daily decision making were intact. The Care Plan dated 1/02/23 read that Resident #125 has a psychiatric disorder r/t bipolar disorder. The focus was resident will have no behavior/maintain behavioral manifestation to a minimum. The intervention for Resident #125 was to refer resident to psychiatric services per physician orders. The Physician's Order Summary (POS) for January read Doxepin HCl Capsule 150 mg Give 2 capsule by mouth at bedtime related to bipolar disorder. Start dated was 1/09/2023. A review of the Medication Administration Record (MAR) revealed that Resident #125 missed 3 days of receiving Doxepin HCI Capsule 150 mg, 2 capsules by mouth at bedtime on the following dates: January 22-January 24-2023. A review of the medical record revealed on 1/22/23 at 9:40 PM., Doxepin HCl Capsule 150 mg on order not in from pharmacy not available in pixis. A review of the medical record revealed on 1/23/23 at 8:53 PM., Doxepin HCl Capsule 150 mg not available. A review of the medical record revealed on 1/24/23 at 10:14 PM., Doxepin HCl Capsule 150 mg Awaiting refill from pharmacy. According to the MAR and Medical Records, Resident #125 did not receive their prescribed Doxepin HCI 150 mg Capsules, for three nights. On 7/24/24 at approximately 7:35 PM., a telephone interview was conducted with Family Member (FM) #3, concerning Resident #125. FM #3 said that she was informed by the resident that she was not administered Doxepin for three nights while residing at the facility. On 07/26/24 at approximately 11:38 AM., an interview was conducted with the Director of Nursing (DON). The DON said that the medication was available. The staff should have administered the Doxepin. On 7/26/24 at approximately 2:10 PM., a final interview was conducted with the Administrator, Director of Nursing (DON), Regional Nurse Consultants and the [NAME] President of Operations. The local state Ombudsman was also present. The facility staff had no additional comments and voiced no concerns regarding the above information deficient practice.

Based on observations, resident interview, staff interview, clinical record review, the facility's staff failed to ensure significant medication was administered for 1 of 49 residents in the survey sample, Resident #125 The findings included: Resident #125 was originally admitted to the facility 1/18/23 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Paranoid Personality Disorder and Bi-Polar Disorder. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/18/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #125 cognitive abilities for daily decision making were intact. The Care Plan dated 1/02/23 read that Resident #125 has a psychiatric disorder r/t bipolar disorder. The focus was resident will have no behavior/maintain behavioral manifestation to a minimum. The intervention for Resident #125 was to refer resident to psychiatric services per physician orders. The Physician's Order Summary (POS) for January read Doxepin HCl Capsule 150 mg Give 2 capsule by mouth at bedtime related to bipolar disorder. Start dated was 1/09/2023. A review of the Medication Administration Record (MAR) revealed that Resident #125 missed 3 days of receiving Doxepin HCI Capsule 150 mg, 2 capsules by mouth at bedtime on the following dates: January 22-January 24-2023. A review of the medical record revealed on 1/22/23 at 9:40 PM., Doxepin HCl Capsule 150 mg on order not in from pharmacy not available in pixis. A review of the medical record revealed on 1/23/23 at 8:53 PM., Doxepin HCl Capsule 150 mg not available. A review of the medical record revealed on 1/24/23 at 10:14 PM., Doxepin HCl Capsule 150 mg Awaiting refill from pharmacy. According to the MAR, Resident #125 did not receive their prescribed Doxepin HCI 150 mg Capsules, for three nights. On 7/24/24 at approximately 7:35 PM., a telephone interview was conducted with Family Member (FM) #3, concerning Resident #125. FM #3 said that she was informed by the resident that she was not administered Doxepin for three nights while residing at the facility. On 07/26/24 at approximately 11:38 AM., an interview was conducted with the Director of Nursing (DON). The DON said that the medication was available. The staff should have administered the Doxepin. On 7/26/24 at approximately 2:10 PM., a final interview was conducted with the Administrator, Director of Nursing (DON), Regional Nurse Consultants and the [NAME] President of Operations. The local state Ombudsman was also present. The facility staff had no additional comments and voiced no concerns regarding the above information.

Based on observations, staff interview and clinical record review, the facility staff failed to ensure a resident with an indwelling catheter received the appropriate care and services to prevent repetitive urinary tract infections (UTIs) for 1 of 49 residents (Resident #76), in the survey sample. The findings included: Resident #76 was originally admitted to the facility 1/16/23 and readmitted to the facility acute care hospital stay on 6/10/24. The current diagnoses included a neurogenic bladder secondary to multiple sclerosis. A neurogenic bladder is an interruption of communication between the brain and the nerves in the spinal cord that the control bladder. People with multiple sclerosis or spina bifida might have similar problems. (https://www.mayoclinic.org/tests-procedures/neurogenic-bladder-bowel-management/about/pac-20394763) The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/15/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #76's cognitive abilities for daily decision making were intact. In section GG0115 A/B Functional Limitation in Range of Motion; the resident was coded to have no impairment of bilateral upper extremities (shoulder, elbow, wrist, hand) and bilateral lower extremities (hip, knee, ankle, foot). At section G0170A, the ability to roll from lying on her back to the left and right side and return to lying on back on the bed was coded as requiring partial/moderate assistance. At section H0100A the resident was coded as utilizing an indwelling catheter. A review of the physician's Order Summary (POS) revealed the following order dated 2/23/24 Foley Catheter, size (16F) and balloon size (5ml) for neurogenic bladder. Another order dated 2/23/24, read change and date the Foley drainage bag on the 15th of every month and as needed. On 7/23/24 during the initial tour at approximately 2:55 PM, Resident #76 was observed in bed with positioned on her back watching television. A bedside drainage bag was observed attached to the bedframe. Again on 7/23/24 at approximately 11:15 AM the resident was in bed. The resident removed the bed linens to allow the surveyor to observe the upper tubing to the catheter. It was identified as an indwelling catheter. During the Infection Control task, Resident #76 was identified to have recurrent UTIs. They included, on 3/6/24 the resident presented with greater than 100,000 colonies of E. coli bacteria, on 4/30/24 she had greater than 100,000 colonies of pseudomonas bacteria, and on 6/7/24 the resident was admitted to the hospital for severe sepsis secondary to a multi-drug resistant E. coli bacteria UTI. Review of the person-centered comprehensive care plan failed to address the resident's need to have a indwelling catheter due to a neurogenic bladder secondary to multiple sclerosis even though it was identified on the resident's comprehensive assessment. Also the person-centered comprehensive care plan failed to provide guidance to the direct care caregivers to decrease opportunities for UTIs by recognizing, reporting and addressing changes. The person-centered comprehensive care plan further failed to prompt the direct care staff to keeping the catheter anchored to prevent excessive tension, securing the catheter to facilitate flow of urine, preventing kinking of the tubing and positioning the tubing/bag below the level of the bladder, keeping the resident and catheter clean of feces to minimize bacterial migration, and adhering to infection control practices when managing the catheter. On 7/25/24 2:10 PM the Infection Preventionist stated she had been conducting ongoing in-services with the staff regarding handwashing but she did not state when E. coli bacterias were identified in urine that she instructed the staff on proper toileting hygiene after having bowel movements. On 7/26/24 at approximately 4:45 PM, a final interview was conducted with the Administrator, Director of Nursing, the Regional Nurse Consultants and the [NAME] President of Operations. They had no comments and voiced no concerns regarding the above information deficient practice.

Based on staff interview and clinical record review, the facility staff failed to develop a person-centered comprehensive care plan for 1 of 49 residents (Resident #76), in the survey sample. The findings included: Resident #76 was originally admitted to the facility 1/16/23 and readmitted to the facility acute care hospital stay on 6/10/24. The current diagnoses included a neurogenic bladder secondary to multiple sclerosis. A neurogenic bladder is an interruption of communication between the brain and the nerves in the spinal cord that the control bladder. People with multiple sclerosis or spina bifida might have similar problems. (https://www.mayoclinic.org/tests-procedures/neurogenic-bladder-bowel-management/about/pac-20394763) The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/15/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #76's cognitive abilities for daily decision making were intact. In section GG0115 A/B Functional Limitation in Range of Motion; the resident was coded to have no impairment of bilateral upper extremities (shoulder, elbow, wrist, hand) and bilateral lower extremities (hip, knee, ankle, foot). At section G0170A, the ability to roll from lying on her back to the left and right side and return to lying on back on the bed was coded as requiring partial/moderate assistance. At section H0100A the resident was coded as utilizing an indwelling catheter. A review of the physician's Order Summary (POS) revealed the following order dated 2/23/24 Foley Catheter, size (16F) and balloon size (5ml) for neurogenic bladder. Another order dated 2/23/24, read change and date the Foley drainage bag on the 15th of every month and as needed. On 7/23/24 during the initial tour at approximately 2:55 PM, Resident #76 was observed in bed with positioned on her back watching television. A bedside drainage bag was observed attached to the bedframe. Again on 7/23/24 at approximately 11:15 AM the resident was in bed. The resident removed the bed linens to allow the surveyor to observe the upper tubing to the catheter. It was identified as an indwelling catheter. Review of the person-centered comprehensive care plan failed to address the resident's need to have a indwelling catheter due to a neurogenic bladder secondary to multiple sclerosis even though it was identified on the resident's comprehensive assessment. The Facility policy titled, Comprehensive Care Planning, documented in part, the following: C) A comprehensive care plan must be developed by the interdisciplinary care planning team with in seven days after completion of the comprehensive MDS. The services provided or arranged by the facility, as outlined by the comprehensive care plan must be provided by qualified persons in accordance with each resident's written plan of care. Be culturally competent and trauma-informed, as indicated. On 7/26/24 at approximately 4:45 PM, a final interview was conducted with the Administrator, Director of Nursing, the Regional Nurse Consultants and the [NAME] President of Operations. They had no comments and voiced no concerns regarding the above information deficient practice.

Based on a resident interview, staff interview, and clinical record review the facility staff failed to assist a resident to schedule an appointment and arrange transportation to and from the vision care center for 1 of 49 residents (Resident #84), in the survey sample. The findings included: Resident #84 was originally admitted to the facility 03/14/2023. The current diagnoses included intellectual disability, paraplegia secondary to a spinal mass and glaucoma. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 06/01/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #84's cognitive abilities for daily decision making were intact. An interview was conducted with Resident #84 on 7/24/24 at 5:37 PM. Resident #84 stated she was so excited because she finally had insurance which afforded her the opportunity to choose a pair of glasses she really wanted, not the refurbished eye glasses. The resident stated she had became super excited after she was notified the that her eye glasses were paid for and ready at the vision care center. The resident stated that on 7/19/22 that she informed the nursing staff that her eyeglasses were ready for picked at the vision care center and she asked the nurse to schedule an appointment on the first available Tuesday or Thursday because the vision care center wanted her to try the glasses on so they could be adjusted if needed prior to delivery. Resident #84 stated as of 7/24/24 the facility's staff had not communicated with her the date and time the appointment would take place. Resident #84 further stated that she was upset to the point that she did not care any longer if she obtained the eyeglasses. On 7/26/24 at 3:40 PM an interview was conducted with the Director of Nursing (DON). The DON stated the resident did not inform the facility staff that the eyeglasses were ready to be picked up until 7/19/24 and the staff made two attempts to schedule an appointment with no success therfore there was no information to relay to the resident. A review of the nurse's notes failed to validated the actions of the facility's staff attempting to make an appointment on behalf of the resident. A text message was provided to the survey team on 7/26/24 at 4:00 PM from Licensed Practical Nurse (LPN) #8 to the Assistant Director of Nursing. The text message stated LPN #8 was informed by Resident #84 that the vision care center had called the facility to convey that Resident #84's glasses were ready for pickup but no one at the facility answered the phone therefore Resident #84's family member was notified. In the text message LPN #8 stated she called the vision care center to confirm the information but she could not reach the vision care staff. Again there was no documentation for other staff members to continue calling the vision care center because LPN #8 failed to document the information. The DON stated that today (7/26/24) they had obtained an appointment for Resident #84 to visit the vision care center on 7/30/24. On 7/26/24 at approximately 4:45 PM, a final interview was conducted with the Administrator, Director of Nursing, the Regional Nurse Consultants and the [NAME] President of Operations. They had no comments and voiced no concerns regarding the above information deficient practice.

Based on resident interviews, staff interviews, and clinical record review, the facility staff failed to schedule and invite the residents and their representatives to participate in care planning for 2 of 49 residents (Resident #10 and #7), in the survey sample. The findings included: 1. The facility staff failed to schedule and invite Resident #10 to participate in her care plan conference after completion of her 6/29/24 significant change Minimum Data Set (MDS) assessment. Resident #10 was originally admitted to the facility 11/2/21. The current diagnoses included a heart attack, a seizure disorder and a meningioma. The significant change MDS assessment with an assessment reference date (ARD) of 6/29/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #10's cognitive abilities for daily decision making were intact. On 07/24/24 at 11:02 AM, an interview was conducted with Resident #10. The resident stated she had not been invited to participate in her care plan conference recently and she did not believe the facility's staff had held her care plan conference because her spouse had not mentioned that he had been invited to participate. An interview was conducted with the Social Services Director (SSD) on 7/26/24 at approximately 1:35 PM. The SSD provided documentation that Resident #10's last care plan conference was last held on 4/18/24 and the resident participated but seven days after completion of the significant change assessment the facility staff failed to schedule and conduct a care plan conference. At the time of the survey's team exit on 7/26/24 the care plan meeting associated with the 6/29/24 MDS assessment had not been scheduled. The facility's 3/2/21 revised policy titled Comprehensive Care Planning at at section F, stated that the comprehensive care plan is reviewed and updated at least every 90 days by the interdisciplinary team. At section G the policy read, In cases of a significant change the resident's condition, the care plan must be updated within seven days of the new full MDS. At section H the policy read A facility Resident Care Plan coordinator (must be a nurse appointed and supervised by the Director of Nursing) is responsible for the Resident assessment, the Resident care plan and the Resident care plan conference. On 7/26/24 at approximately 4:45 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), the Regional Nurse Consultants and the [NAME] President of Operations. The DON stated that Resident #10 had a brain tumor and she was certain that what she stated was not correct. The DON investigated the above information and return later confirming Resident #10 was accurate and she had not had a care plan conference since 4/18/24. The Facility staff had no additional comments and voiced no further concerns regarding the above information deficient practice. 2. The facility staff failed to schedule and invite Resident #7 to participate in her care plan conference after completion of her 6/30/24 quarterly Minimum Data Set (MDS) assessment. Resident #7 was originally admitted to the facility 3/22/24. The The current diagnoses included multiple sclerosis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #7's cognitive abilities for daily decision making were intact. On 07/24/24 at 12:11 PM, an interview was conducted with Resident #7. The resident stated it had been a long time since she had been invited to attended a care plan conference and she was sure her son had not participated in a care plan conference without her. An interview was conducted with the Social Services Director (SSD) on 7/26/24 at approximately 1:35 PM. The SSD provided documentation that Resident #7's last care plan conference was last held on 3/28/24 and the resident participated but seven days after completion of the 6/30/24 quarterly assessment the facility staff failed to schedule and conduct a care plan conference. At the time of the survey's team's exit on 7/26/24 the care plan meeting associated with the 6/30/24 MDS assessment had not been scheduled, therefore the resident and her representative still had not been invited to participate. The facility's 3/2/21 revised policy titled Comprehensive Care Planning at at section F, stated that the comprehensive care plan is reviewed and updated at least every 90 days by the interdisciplinary team. At section G the policy read, In cases of a significant change the resident's condition, the care plan must be updated within seven days of the new full MDS. At section H the policy read A facility Resident Care Plan coordinator (must be a nurse appointed and supervised by the Director of Nursing) is responsible for the Resident assessment, the Resident care plan and the Resident care plan conference. On 7/26/24 at approximately 4:45 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), the Regional Nurse Consultants and the [NAME] President of Operations. The Facility staff had no additional comments and voiced no concerns regarding the above information deficient practice.

Based on observations, staff interview, resident interview and clinical record review, the facility staff failed to ensure reasonable accommodation of needs for two alert Residents (Resident # 63 and # 64) in a survey sample of 49 residents. 1. For Resident # 63, the facility staff failed to ensure the large clock on the bedroom wall was working. The room was shared with a roommate (Resident # 64) who also was alert and oriented. Resident # 63 was admitted to the facility with the diagnoses of, but not limited to, Cerebral Vascular Infarction and Aphasia. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 4/26/2024. Resident # 63's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Review of the clinical record was conducted on 7/232024-7/26/2024. During the initial tour on 7/23/2024 at 1:15 p.m., the clock on the wall near the dresser in Resident # 63's room was observed to have the time of 5:57. Resident # 63 was in the room, lying in the bed and watching television. Resident # 63 was alert, oriented and able to converse with the surveyor. The room was shared with a roommate (Resident # 64). On 7/23/2024 at 2:10 p.m., the clock had the time of 5:57. On 7/23/2024 at 2:40 p.m., the clock had the time of 5:57. The second hand was not moving. Resident # 63 was observed sitting in his wheelchair and propelling himself in the hallway. He stated he was going back to his room after participating in an activity. On 7/23/2024 at 3:00 p.m., the clock had the time of 5:57. Resident # 63 was lying on his bed watching TV. On 7/23/2024 at 4:40 p.m., the clock had the time of 5:57. Resident # 63 was lying in bed. On 7/24/2024 at 9:45 a.m., the clock had the time of 5:57. Resident # 63 was lying in bed listening to music. On 7/24/2024 at 1:30 p.m., the clock had the time of 5:57. Resident # 63 was not in the room. On 7/24/2024 at 1:50 p.m., the clock had the time of 5:57. Resident # 63 was not in the room. On 7/24/2024 at 4:40 p.m., the clock had the time of 5:57. Resident # 63 was lying in bed watching television. On 7/25/2024 at 8:30 a.m., the clock had the time of 5:57. Resident # 63 was lying in bed watching television. During the interview, Resident # 63 stated he looks at the clock but it is wrong. Stated he would use the clock if it was correct. Resident stated he had to use his cell phone or the clock at the nurses station to get the correct time. Staff persons were observed in the room picking up food trays, delivering ice and water and providing care to Resident # 63 during the survey. No staff person addressed the issue of the clock having the wrong time. On 7/25/2024 at 2:05 p.m., an interview was conducted with the Unit Manager who stated Resident # 63 was alert and oriented. The Unit Manager went to the room with the surveyor, looked at the clock and stated the time showed 5:57. The Unit Manager stated the clock in the room should have had the correct time because it was important for the orientation of the residents. The Unit Manager was informed that the time on the clock showed the time of 5:57 during each observation of the survey. The Unit Manager stated staff members should have observed the clock was wrong. During the end of day debriefing on 7/25/2024, the Facility Administrator , the Regional [NAME] President of Operations, and Director of Nursing were informed of the issue. They all stated the clocks in residents' rooms should be accurate. The Director of Nursing, she stated it was important for clocks to be accurate because they would help with orientation of the residents. The Director of Nursing stated the staff members should have observed that the clock was not working. No further information was provided. 2. For Resident # 64, the facility staff failed to ensure the clock in the bedroom was working. The room was shared with a roommate (Resident # 63) who also was alert and oriented. Resident # 64 was admitted to the facility with the diagnoses of, but not limited to Hypertension. The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 6/13/2024. The MDS for Resident # 64 was coded with a BIMS (Brief Interview for Mental Status) Score of 15 out of 15 indicating no cognitive impairment. Review of the clinical record was conducted on 7/23/2024-7/26/2024. During the initial tour on 7/23/2024 at 1:15 p.m., the clock on the wall near the dresser in Resident # 64's room was observed to have the time of 5:57. Resident # 64 was in the room, sitting in his wheelchair and watching television. Resident # 64 was alert and able to converse with the surveyor. The room was shared with a roommate (Resident # 63) who also was alert and oriented. On 7/23/2024 at 2:40 p.m., the clock had the time of 5:57. The second hand was not moving. Resident # 64 was observed propelling himself in his wheelchair the hallway. He stated he was going back to his room after participating in an activity. On 7/23/2024 at 4:40 p.m., the clock had the time of 5:57. Resident # 64 was sitting in his wheelchair watching television. On 7/24/2024 at 9:45 a.m., the clock had the time of 5:57. Resident # 64 was sitting in his wheelchair in the room. On 7/24/2024 at 1:30 p.m., the clock had the time of 5:57. Resident # 64 was not in the room. On 7/24/2024 at 1:50 p.m., the clock had the time of 5:57. Resident # 64 was sitting in the wheelchair in the room. When asked if he could tell time, he replied yes. Resident # 64 looked over at the clock when asked what time the next Activity was scheduled. Resident # 64 looked and the clock and stated the clock was wrong. He stated he had to look at his cell phone to get the time. Resident # 64 began looking for his cell phone. Resident # 64 located the cell phone and stated the correct time. Resident # 64 stated the Activities personnel would let him know when it is time to go to Activities. On 7/24/2024 at 4:40 p.m., the clock had the time of 5:57. Resident # 64 was sitting in his wheelchair in his room and watching television. On 7/25/2024 at 8:35 a.m., the clock had the time of 5:57. Resident # 64 was sitting in his wheelchair watching television. Staff persons were observed in the room delivering and picking up food trays, delivering ice and water and providing assistance to Resident # 64 during the survey. No staff person addressed the issue of the clock having the wrong time. On 7/25/2024 at 2:05 p.m., an interview was conducted with the Unit Manager who stated Resident # 64 was alert and oriented. The Unit Manager went to the room with the surveyor, looked at the clock and stated the time showed 5:57. The Unit Manager stated the clock in the room should have had the correct time because it was important for the orientation of the residents. The Unit Manager was informed that the time on the clock showed the time of 5:57 during each observation of the survey. The Unit Manager stated staff members should have observed the clock was wrong. During the end of day debriefing on 7/25/2024, the Facility Administrator, the Regional [NAME] President of Operations, and the Director of Nursing were informed of the issue. They all stated the clocks in residents' rooms should be accurate. The Director of Nursing, she stated it was important for clocks to be accurate because they would help with the orientation of the residents. The Director of Nursing stated the staff members should have observed that the clock was not working. No further information was provided.

Based on a resident interview, staff interview, and clinical record review the facility staff failed to treat residents with respect and dignity for 1 out of 49 residents (Resident #84) in the survey summary. The findings included: The facility staff failed to notify the resident that her ice cream was mishandled resulting in a non-consumable thawed state. Resident #84 was originally admitted to the facility 03/14/2023. The current diagnoses included intellectual disability, paraplegia secondary to a spinal mass and glaucoma. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 06/01/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #84's cognitive abilities for daily decision making were intact. An interview was conducted with Resident #84 on 7/24/24 at 5:37 PM. Resident #84 stated on 7/1/24 her sister brought in ice cream for her and her sister asked the facility's staff to label and store it until it was consumed by the resident. Resident #84 stated the staff accepted the ice cream from her sister. The resident stated later that day when she requested the some of the ice cream and she was told that she did not have ice cream in the freezer. Resident #84 further stated she asked the certified nursing assistant (CNA) to please look again because she knew her sister had left the ice cream with the staff. Resident #84 stated the CNA returned and informed her that the ice cream was not put in the freezer at the time it was received from her sister and the ice cream was observed on top of the freezer, thawed and not consumable. Resident #84 stated the information was very upsetting and she felt that the staff should have notified her that the ice cream had not been handled properly. Resident #84 stated she had prepared herself to enjoy eating the ice cream but learned it was not consumable. On 7/26/24 at 3:40 PM an interview was conducted with the Director of Nursing (DON). The DON stated that the staff who accepted the ice cream from the Resident's sister did not report that they failed to properly store the ice cream and neither did the staff who identified the melted ice cream report the event. The DON also stated that the resident did not voice her concern about the ice cream until 7/23/24 to LPN #3 and on she 7/24/24 took action and replaced the ice cream. The resident did not state during our interview on 7/24/24 at 5:37 PM that the facility staff apologized for the mishandling of her ice cream or replaced her ice cream on 7/24/24. The documentation in the resident record related to the mishandled ice cream and communication with the resident was dated 7/25/24. On 7/26/24 at approximately 4:45 PM, a final interview was conducted with the Administrator, Director of Nursing, the Regional Nurse Consultants and the [NAME] President of Operations. The DON voiced the resident should have reported the mishandling of her ice cream sooner. There were no further comments or voiced concerns regarding the above information deficient practice.

Based on observations, staff interview, and clinical record review, the facility staff failed to demonstrate alternatives were attempted prior to installing side rails to the bed of 1 of 49 residents (Resident #76), in the survey sample. The findings included: Resident #76 was originally admitted to the facility 1/16/23 and readmitted to the facility acute care hospital stay on 6/10/24. The current diagnoses included a stroke, malnutrition, depression, and multiple sclerosis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/15/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #76's cognitive abilities for daily decision making were intact. In section GG0115 A/B Functional Limitation in Range of Motion; the resident was coded to have no impairment of bilateral upper extremities (shoulder, elbow, wrist, hand) and bilateral lower extremities (hip, knee, ankle, foot). At section G0170A, the ability to roll from lying on her back to the left and right side, and return to lying on back on the bed was coded as requiring partial/moderate assistance. On 7/23/24 during the initial tour at approximately 2:55 PM, Resident #76 was observed in bed with positioned on her back watching television. Bilateral quarter (1/4) side rails were observed in the up position to the bed. Again on 7/26/24 at approximately 2:25 PM the resident was observed to have bilateral quarter side rails to the bed. Resident #76 stated she is assisted by the nurses to turn change positions in bed. The Physician's Order Summary (POS) revealed an order dated 2/23/24 for 1/4 bed rails for bed mobility. The resident's care plan had a problem dated 5/24/24 which read; activities of daily living (ADLs) Functional Status/Rehabilitation Potential. (name of the resident) has self-care deficit and requires assistance with ADLs related to a diagnosis of multiple sclerosis and decreased mobility. The goal read; Resident needs will be met. The interventions included 1/4 bed rails to promote mobility. The resident's clinical record contained a Bed Rail assessment completed on 01/19/24 which stated, the resident had a medical need for the side rail being considered. The medical need was identified as resident mobility and the resident benefits from use of the side rail was documented as resident mobility. On 7/26/24 at 3:40 PM an interview was conducted with the Director of Nursing (DON). The DON stated the resident had 1/4 rails to her bed for bed mobility and she had consented to them, but the DON documentation failed to reveal the resident's signature for consent of the side rails Also the DON failed to provide evidence that alternatives were attempted prior to use of side rails, or that a review of risks including entrapment was discussed with resident prior to installation of the side rails. On 7/26/24 at approximately 4:45 PM, a final interview was conducted with the Administrator, Director of Nursing, the Regional Nurse Consultants and the [NAME] President of Operations. They had no comments and voiced no concerns regarding the above information deficient practice.

Based on observation and staff interview the facility staff failed to properly thaw and store chicken and the facility staff failed to appropriately label and date refrigerated and un-refrigerated food items. The findings include: On 7/23/24 at approximately 12:30 PM observations were made of: loaves of bread with no expiration dates on the bread rack, opened milk with no used by date in the walk-in refrigerator and open slice cheddar cheese in a plastic bag with no label or date. On 7/24/24 at approximately 12:30 PM an observation was made of the chicken legs that were thawed to be used by 7/23/24, were refrozen in the facility's freezer in clear plastic bags dated 8/31/24. An interview was conducted with Others #8 (dietary staff) on 7/24/2024 at approximately 2:30 PM. Others #8 shared that everything gets dated on the day of delivery with the delivery date. She shared when an item is opened and not completely used, the open and discard date should be written on the item. Others #8 indicated that once chicken is thawed and stored in the walk-in refrigerator, it should not be refrozen. An interview was conducted with Others #9 (dietary staff) on 7/24/2024 at approximately 3:10 PM. Others #9 shared that when a product in the kitchen is opened, staff should put a open and discard date on the product. An interview was conducted with the Dietary Manager on 7/25/2024 at approximately 1:00 PM. The Dietary Manager shared that the stock staff put a delivery date on everything as it is put away. He shared that staff should put a open and discard date on all items opened and not completely used. The Dietary Manager acknowledged the thawed chicken from 7/23/2024 should not have been refrozen and that he was not aware. Review of the facility's policy Food Preparation and Handling with a revision date of 1/5/2023, indicated foods would be appropriately labeled and dated. The above findings were shared with the Administrator, the Director of Nursing, Corporate Nurse ,Vice President of Operations, and Ombudsman on 7/26/2024 at approximately 5:15 PM. No further information was provided prior to the conclusion of the survey.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide respiratory care consistent with professional standards of practice for 1 Resident (#94) in a survey sample of 49 Residents. The findings included: For Resident #94 the facility staff failed to ensure oxygen and nebulizer tubing were changed according to physician order. On 07/23/24 at 02:15 PM observation was made of Resident # 94's oxygen and nebulizer tubing dated 7/14/24, the humidification bottle attached to the oxygen concentrator was not dated. A review of the clinical record revealed that the orders for nebulizer and oxygen read: Clean oxygen concentrator and filter, change tubing weekly (Q 7 days). The MAR (Medication Administration Record) was signed off as being done on 7/14/24 and 7/21/24. On the morning of 7/24/24 an interview was conducted with LPN #3 who was asked when the oxygen tubing gets changed, she stated that it is done on night shift once a week on Sunday. When asked about the tubing on Resident #94's oxygen and nebulizer she stated that it must have gotten missed. On 7/26/24 an interview with the DON was conducted and she was asked the expectation of nurse changing oxygen and nebulizer tubing, she stated that it was her expectation that it be changed according to policy which is weekly. When asked if that was done in this case, she stated that it was not. On 7/26/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observations, clinical record review, staff and resident interviews, the facility staff failed to provide personal hygiene to include full body showers and or whirlpools with hair washing for 4 of 41 residents (#64, #52, #19 and #53) in the survey sample. The findings include: 1. Resident #64 was not receiving personal hygiene to include showers and hair shampoos since 12/25/20. Resident #64 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) assessment was an Annual dated 1/25/21 and coded Resident #64 with a 15 out of a possible score of 15 which indicated the resident was intact with the skills needed for daily decision making. The MDS assessed the resident to not reject care. The resident was assessed totally dependent on one staff for dressing, personal hygiene and bathing. Resident #64 required extensive assistance of one staff for bed mobility, transfer, eating and toilet use. The resident was coded not steady and only able to stabilize herself with staff assistance for moving from seated position, moving off the toilet and surface to surface transfer. The resident was assessed impaired on both sides of upper extremity in range of motion. The resident was assessed to use a wheelchair. Resident #64 was assessed frequently incontinent of bowel and bladder. The care plan dated 8/23/19 identified self-care deficit and that Resident #64 required assistance with Activities of Daily Living (ADL). The goal set by the staff was that the resident's ADL needs would be met. Some of the approaches the staff would implement to accomplish this goal included assist with ADLs, dressing, grooming, toileting, feeding and oral care. On 3/10/21 at 12:15 p.m., Resident #64 was observed in her wheelchair in her room. She stated she could not remember the last time she had a shower and her hair washed, It has been months. I only get hand baths. She stated even though she wore a wig, she still would love to have her hair washed and it had been months. Strands of her natural hair was observed at the nape of her neck from under her wig. There was no record of showers or documentation that the resident's hair had been washed since 12/25/20 when droplet precautions for COVID-19 were discontinued. On 3/12/21 at 10:20 a.m., the Director of Nursing (DON) presented the aforementioned documentation that indicated the resident was off transmission based precautions on 12/25/20, thus the aides could have restarted showers for Resident #64. On 3/12/21 at 12:05 p.m., this surveyor and the Administrator went to the resident's room at which time, without any prompting, Resident #64 asked the Administrator if she could make sure her hair was washed and showers resumed. The Administrator stated as long as a resident was not on transmission based precautions, they could be given a shower and their hair shampooed. She reassured the resident her showers and shampoos would resume. On 3/12/21 at 3:40 p.m., during the debriefing with the Administrator, Director of Nursing (DON) and the Regional Corporate Nurse, no further information was provided prior to survey exit. 2. Resident #52 was not receiving personal hygiene to include showers and hair shampoos since 12/22/20. Resident #52 was originally admitted to the nursing facility on 10/2/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) assessment was dated 1/12/21 and coded Resident #52 with a 15 out of a possible score of 15 which indicated the resident was intact with the skills needed for daily decision making. The MDS assessed the resident to not reject care. The resident was assessed to need supervision and support from one staff for bathing and personal hygiene. She was coded occasionally incontinent of urine and frequently incontinent of bowel. The care plan dated 1/27/21 identified the resident with ADL self care performance deficit related to limited mobility and required assistance with ADLs. The goal set by the staff for the resident included the resident would maintain her current level of function and resident needs would be met. Some of the approaches the staff would implement to accomplish this goal included assist with ADLs, dressing, grooming, toileting, feeding and oral care. On 3/10/21 at 12:15 p.m., Resident #52 was observed in her wheelchair in her room. She stated she was told because of the Pandemic only wash-ups could be done and once she was set up, she washed herself, but would love to restart her whirlpool and have her hair washed. She stated, I would feel so much better if I could get my whirlpools back and I would love my head washed. Even though I am bald on top, my head is a part of my body and it should be washed too. She wore a wig and gray hair was visible around the edges of the wig. There was no record of showers or documentation that the resident's hair had been washed since 12/22/20 when transmission based precautions were discontinued. On 3/12/21 at 10:20 a.m., the Director of Nursing (DON) presented the aforementioned documentation that indicated the resident was off transmission based precautions on 12/22/20, thus the aides could have restarted whirlpools for Resident #52. On 3/12/21 at 12:05 p.m., this surveyor and the Administrator went to the resident's room at which time, without any prompting, Resident #52 asked the Administrator if she could make sure her hair was washed and whirlpools resumed. The Administrator stated as long as a resident was not on transmission based precautions, they could be given a shower/whirlpool and their hair shampooed. Resident #52 asked the Administrator if she was sure she could have her whirlpools and her hair washed. The resident wanted to know if she needed to provide the hair shampoo. The Administrator reassured the resident that the facility would provide shampoo and her whirlpools would resume. On 3/12/21 at 3:40 p.m., during the debriefing with the Administrator, Director of Nursing (DON) and the Regional Corporate Nurse, no further information was provided prior to survey exit. 3. Resident #19 was not receiving personal hygiene to include showers since 2/18/21. Resident #19 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #19's Minimum Data Set (an annual assessment) with an Assessment Reference Date of 11/07/20 coded Resident #19 with a BIMS (Brief Interview for Mental Status) score of 13 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #19 as requiring supervision of 1 person for bed mobility, and eating. Limited assistance of 1 person with dressing. Extensive assistance of 1 for personal hygiene. 1 person physical assistance with bathing. Independence with transfers. Careplan: The careplan reads that Resident #19 has a Self care deficit. -refuses teds at times, refuses showers. Goals: Residents needs will be met with regard to adl's through next review. Interventions: Break tasks down so that adl's are easier for resident to perform and encourage resident participation while performing adl's. During the tour on 03/11/21 9:39 AM Resident #19 was observed lying in bed. She was asked if she was taking baths and what days were her showers scheduled. She stated, They don't give me any showers. I want to start taking showers. CNA (Certified Nurse's Aide) #3 walked in. Resident #19 stated I feel like I have sand in my socks. CNA #3 replied, I'm getting ready to give you care now. What do you want a bath or shower. Resident #19 replied. A shower. A review of the B-Wing shower book on 3/11/21 showed Resident #19, should receive showers on Monday and Thursdays during the 7A-3P Shower List. The shower list reads: Every resident is to be offered a shower, if they refuse, put refused. This is completed daily. The shower list shows that Resident #19 did not receive any showers for the months of February and March. Resident should have received showers on the following days during 7A-3P shift. The January shower list is not available per LPN #2. The list for February was only available from 2/18/21 - 2/27/21. Scheduled days were Mondays and Thursdays 7 AM-3 PM no showers were given on the following scheduled dates: 2/18, 2/22 and 2/25, 3/01, 3/04 and 3/08/21. On 3/11/21 at 9:53 AM an interview was conducted with LPN (Licensed Practical Nurse) #2 concerning Resident not receiving any showers. She stated, The DON (Director of Nursing) said everyone that has been vaccinated on this unit can receive a shower. On 03/11/21 at 10:23 AM CNA #3 was seen transporting resident #19 via wheel chair to the shower room. On 3/12/21 at 10:15 am an interview was conducted with Resident #19 concerning her getting her scheduled shower today. She was asked how did taking the shower make her feel. She stated, Wonderful. I haven't had a shower in a while. I get a bed bath everyday. My feet are feeling better today. No sand but sore today. 4. Resident #53 was not receiving personal hygiene to include showers and hair shampoos since 2/20/21. Resident #53 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #53's Minimum Data Set (an Admission assessment) with an Assessment Reference Date of 1/17/21 coded Resident #53 with a BIMS (Brief Interview for Mental Status) score of 3 indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #53 as requiring extensive assistance of 1 person with dressing, and personal hygiene. Requires extensive assistance of 2 persons for bed mobility. Requires 1 person physical assistance with eating. Requires total dependence with bathing. On 03/11/21 at 10:12 AM Resident #53 was seen ambulating in the hallway with OSM #2 (Physical Therapist) her hair appeared matted and uncombed. A review of the B-Wing shower book shows Resident #53, should receive showers on Wednesdays during the 7A-3P Shower List. The shower list reads: Every resident is to be offered a shower, if they refuse, put refused. This is completed daily. The shower list shows that Resident #53 did not receive any showers for the months of February and March. Resident should have received showers on the following days during 7A-3P shift on Wednesday and Saturdays. The January shower list is not available per LPN #2. The list for February was only available from 2/18/21 - 2/27/21. Scheduled shower days were Wednesdays and Saturdays 7 AM-3 PM no showers were given on the following dates: 2/20, 2/24, 2/27, 3/03, 3/06, 3/10/21. Careplan: Reads that Resident #53 has a self-care deficit relating to disease processes and needs assistance with ADLs (Activity of Daily Living). Goal: Resident needs will be met. Interventions: Assist with activities of daily living, dressing, grooming, toileting, feeding, oral care. On 03/12/21 at 9:49 AM an interview was conducted with LPN #2 concerning Resident #53 receiving showers on Wednesday and Saturdays. She stated, It should be initialed in the book when completed. Lately they haven't been documenting on the ADL sheets. On 03/12/21 at 9:55 AM an interview was conducted with CNA #6 concerning Resident #53. She stated, I don't have her most of the time. She's not my normal. Showers are given on 3 different shifts. If a resident refuses showers we tell the nurse and she documents in the chart and we put an R (for Refusal) and initial in the book. On 3/12/21 at 9:59 AM an interview was conducted with LPN #3 concerning Residents not receiving showers. She stated, No one told me they refused showers. When they were on isolation they weren't allowed to leave their rooms. Resident #53 was on isolation on the C unit for 3 weeks. She was admitted on [DATE] to 1/26/21 and came to this unit on 1-26-21. On 3/12/21 at 10:12 AM an interview was conducted with Resident #53 concerning her receiving showers. She stated, I don't think I can get showers because of this thing (pointing to peg tube). My hair itches. Can you say something to them? It (her hair) hasn't been washed since Christmas. On 03/11/21 at 12:34 PM the DON was interviewed concerning Residents not receiving their showers. She stated, Unless the person is on isolation people should be getting showers. On 3/11/21 at 3:00 PM a phone call was made to Resident's daughter to request a resident representative interview. She stated that her sister was the RP (Responsible Party) for her mom but they both were concerned that their mother was not receiving showers or getting her hair washed. The daughter was reassured by surveyor that the issue would be investigated. On 3/12/21 at 12:30 PM an interview was conducted with CNA #3 concerning resident receiving showers. She stated, We had COVID-19 and they (Residents) were on isolation. Most of the time they do get a shower if they want it. We have shampoo bags. We wash their hair as often as needed. I will ask if you want your shower I ask them if they want their hair washed. I will use the shower cap. Policy: Resident Bath/Showering/Scheduling Policy. Effective: 1/01/2008. Last Revision Date: 02/01/2021. Reads: Residents will be bathed or showered according to their preferences in order to maintain healthy hygiene and skin condition. (A). Each Resident will be asked about his/her bathing preference upon admission (type of bath, preferred days and times). (B). Each resident will be scheduled to receive bathing a minimum of two times per week unless they prefer less frequent baths or state regulation requires more frequent bathing. (C). The facility will develop and maintain a bathing/shower schedule for each unit. (D). At the beginning of the shift the Charge Nurse will review the bathing schedule for that day and shift with the nursing assistants. (E). When the bath or shower is complete the nursing assistant will document the activity on the shower sheet or in point of care section of the electronic record. (G). A shower sheet will be completed for each bath/shower given. (H). If the bath/shower cannot be given or the resident refuses, the nursing assistant will promptly report this to the Charge Nurse. Policy: Morning Care/AM Care. Effective: January 2011. Last Revision Date: 6/15/2020. Morning Care will be offered each day to promote resident comfort, cleanliness, grooming and general wellbeing. Residents who are capable of performing their own personal care are encouraged to do so but will be provided with setup assistance if needed. Showers and baths are scheduled three times weekly or more or less often according to resident preference. Procedure: Assemble supplies: Basin, soap/shampoo, comb/brush, lotion, oral care supplies, nail care supplies, linen, garments, incontinent supplies if needed. #5. Provide bath/shower as indicated. #13. Brush/comb hair. On 03/12/21 at 1:22 PM an interview was conducted with the DON and the Administrator concerning the above Residents not receiving their showers. No comments were made.

Based on observation, staff interview, and facility document review, it was determined that facility staff failed to follow infection control practices while picking up meal trays from quarantine rooms on the C-Wing. The findings included: On 3/10/21 at 1:45 p.m., observations were made of CNA (Certified Nursing Assistant) #1 collecting meal trays from C-Wing, hallway (C-17 through C-22); the quarantine unit. All rooms on the quarantine unit had signage in front of each room documenting the following: Droplet-Contact Precautions Perform hand hygiene, Wear mask before entering the room, Gown before entering the room, Gloves before entering the room, eye protection before entering the room. At 1:50 p.m., CNA #1 was observed entering room C-20 wearing an N95 mask and face shield. CNA #1 failed to don a gown and gloves prior to entering the room. At 1:51 p.m., CNA #1 left room C-20, placed the meal tray on the cart and entered room C-22 without sanitizing her hands. CNA #1 also failed to don a gown and gloves prior to entering room C-22. CNA #1 was then observed leaving room C-22 without sanitizing her hands. CNA #1 placed the meal tray on the cart and entered room C-21 without sanitizing hands. CNA #1 also failed to don a gown and gloves prior to entering C-21. At 1:54 p.m., CNA #1 was observed leaving room C-21 without sanitizing her hands. CNA #1 then placed the meal tray on the cart, went directly to the clean linen cart and grabbed a wash cloth. CNA #1 did not sanitize her hands prior to touching the clean linen cart. CNA #1 was then observed going back into room C-21 without a gown and gloves in place. At 1:55 p.m., CNA #1 was observed leaving room C-21 and then sanitized her hands. On 3/12/21 at 10:00 a.m., an interview was attempted with CNA #1. She could not be reached. On 3/12/21 at 10:03 a.m., an interview was conducted with CNA #2, another nursing aide on the quarantine unit. When asked the process of picking up meal trays for residents on quarantine (Droplet) precautions; CNA #2 stated that when picking up meal trays she is supposed to put on a gown, gloves, and have her N95 mask and shield already in place. CNA #2 stated that she will grab the meal tray and then set the tray on the sink so she can doff her gown and gloves prior to exiting the room. CNA #2 stated that she will then either wash or sanitize her hands and then leave the room. CNA #2 stated that hands must be sanitized prior to picking up another meal tray. This writer made her aware of some staff not donning gowns and gloves prior to entering the quarantine rooms when picking up meal trays on Wednesday during lunch. CNA #2 stated that sometimes, Not going to lie, sometimes I forget because we are not providing care; just grabbing the tray real quick. Also made aware of staff not sanitizing or washing hands prior to leaving room and before picking up another tray. CNA stated that staff were supposed to sanitize hands in between each room. On 3/12/21 at 12:52 ASM #1 was made aware of above concerns. When asked if she expected staff to don gown and gloves when picking up meal trays for residents on the quarantine unit, ASM #1 stated that she did. When asked if she expected staff to sanitize hands between each room, ASM #1 stated that she did or after the meal trays were dropped off on the meal cart. Policy titled, Handwashing in the Kitchen, documents in part, the following: When to wash hands .Before distributing trays/meals to resident. Policy titled, Droplet Precautions,- intended to prevent transmission of pathogens spread through close respiratory or mucous contact with respiratory secretions .c. Gloves, gown, eye protection are worn adhering to Standard Precautions guidelines .F) Handle resident-care equipment and instructions /devices, laundry, dishware, or eating utensils and environment cleaning with Standard Precautions unless more stringent disinfection is indicated .

Based on a complaint investigation, observations, staff and resident interviews and facility documentation, the facility staff failed to accurately assess and provide effective pressure relief while in sitting in a wheelchair to prevent pressure ulcers for 1 of 41 residents (Resident #64) in the survey sample. The findings include: Resident #64 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) assessment was an Annual dated 1/25/21 and coded Resident #64 with a 15 out of a possible score of 15 which indicated the resident was intact with the skills needed for daily decision making. The MDS assessed the resident to not reject care. The resident was assessed totally dependent on one staff for dressing, personal hygiene and bathing. Resident #64 required extensive assistance of one staff for bed mobility, transfer, eating and toilet use. The resident was coded not steady and only able to stabilize herself with staff assistance for moving from seated position, moving off the toilet and surface to surface transfer. The resident was assessed impaired on both sides of upper extremity in range of motion. The resident was assessed to use a wheelchair. Resident #64 was assessed frequently incontinent of bowel and bladder. The resident was coded with weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was on a therapeutic, mechanically altered diet. The resident's height and weight was recorded as 5 ft. 3 in and 105 lbs. Based on the Braden Scale formal assessment instrument and clinical assessment, Resident #64 did not have any current pressure ulcers/injuries, but was coded at risk for them. The assessment indicated the resident had pressure reducing devices for the chair and bed, nutrition or hydration interventions and applications of ointments and medications other than feet for skin and ulcer/injury treatments. The care plan dated 8/23/19 to current identified that the resident was at risk for impaired skin integrity related to decreased mobility, incontinence, diabetes and cognition. The goal the staff set for the resident was that the area would show improvement and be free of signs and symptoms of infection. Some of the approaches the staff would take to accomplish this goal included elevate heels, monitor and report to physician redness, swelling, local warmth, tenderness, discharge and elevated temperature, nutritional status, skin prep per orders, turn and reposition as indicated and wheelchair cushion. Resident #64 was care planned for COVID-19 virus on 12/15/20 and droplet precautions/isolation ordered. On 3/10/21 at 12:15 p.m., Resident #64 was observed in her wheelchair, sitting on a black cushion. She possessed a constant tremor of both arms, hands, as well as facial twitches of eyes and lips. The condition of the cushion was not visible during this observation. The resident stated she had been up in the chair since around 9:30 a.m. The resident stated she got up in the morning and usually laid down and was changed before dinner. She stated the nursing staff did not routinely lift, stand or reposition her while she was in the chair. Certified Nursing Assistant (CNA) #8 placed the resident in bed at 4:00 p.m. for a rest before dinner. The cushion had a plastic cover and observed creased and dipped in the center with an obvious warped bubbled appearance rips along the edges. Sacral wound pressure ulcer observation: On 3/11/21 at 12:32 p.m., Licensed Practical Nurse (LPN) #8 (wound care nurse) accompanied by LPN #7 transferred Resident #64 to bed to provide treatment to a sacral pressure ulcer. The area was described by LPN 8 as a *Stage III with slough (slough is soft necrotic/dead tissue), .9 cm (centimeters) length by (x) .5 cm width. The wound was cleansed with normal saline followed by Santyl (topical debridement) and covered with a boarded dressing. LPN #8 stated she was the nurse to stage wounds due to her training and LPN #7 covered in her absence. LPN #8 also stated she performed wound care treatments on Wednesdays and Thursdays with the licensed nurse's to provide treatments the remaining days. LPN #8 said the physician took her description of wounds and recommendation for treatment, but if wounds require the physician to observe, she will either take a picture and send it to the physician or if necessary, he or she will come in. LPN #8 stated the sacral pressure ulcer was facility acquired and when asked about the etiology of the wound she responded, She got this pressure area from sitting up in her wheelchair too long, but she has a cushion. The resident spoke up and said, I thought I was going to get a new cushion, this one bends in the middle. The cushion was the same one as observed the previous day in the wheelchair. LPN #7, stated the resident's wheelchair cushion was called a non-specific cushion which indicated it was a basic wheelchair cushion. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *Stage III involves the full thickness of the skin and may extend into the subcutaneous tissue layer; granulation tissue and epibole (rolled wound edges) are often present. At this stage, there may be undermining and/or tunneling that makes the wound much larger than it may seem on the surface (Information retrieved on 3/15/21 from document Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 40, 2019). Right foot wound observation: The LPN #8, wound care nurse, and LPN #7 prepared to perform wound care to the right heel. LPN #7 proceeded to pull up Resident #64's right pant leg when she observed significantly greater swelling of the right leg/foot than the left, pitting [CONDITION(S)]. LPN 7 stated, (Resident #64's name) we have to take these socks off and find something looser. When the existing dressing was removed, an inflamed reddened area was observed on the resident's medial heel with an open area. The resident said she did not feel anything was there. LPN #8 did not hesitate to state the right heel was a diabetic ulcer and appeared to be a divit on the sole of the resident's foot the previous day (3/10/21). She said a divit was like an open dent and it was first identified on 3/4/21, but today I may be leaning more towards a *Stage II because it is more towards the bony prominence? It could still be a diabetic ulcer. She stated they needed to keep pressure off the area and would have the resident leave her shoes off for a few days. They stated, Her diabetic shoes have been ordered which will give her more room and avoid any pressure to her heels. LPN#8 was asked to provide professional documentation to support that this area on the resident's bony prominence of the medial heel was a diabetic ulcer and not the result of [CONDITION(S)] and pressure from a malfitting tight shoe. The documentation was not provided prior to survey exit. *A Stage II is a Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed without slough. May also present as an intact or open/ruptured serum-filled blister (information retrieved on 3/15/21 from document Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 39, 2019). The resident was observed back up in her wheelchair on 3/11/21 at 1:15 p.m. for the lunch meal. The shoes remained off. On 3/11/21 at 2:38 p.m., Resident #64 stated she thought she got a new cushion, but the one she had was dipped in the center and it was not what I thought I was going to get. She said she was not able to push up on the arms of the wheelchair to reposition her lower body and buttocks without help, but the staff did not reposition her while in the wheelchair and that was why she wanted a more comfortable cushion. The resident was observed in the wheelchair at 4:05 p.m. The first documentation by the Unit Manager (UM) LPN #6 of the sacral wound was dated 2/27/21 as 1 cm (length) by 1 cm (width) and 0.1 cm depth, no drainage, pink wound bed, no odor, pink periwound and in house acquired. The physician was notified and treatment included [MEDICATION(S)] dressing every three days and that the resident was made aware of small open area on bony area of coccyx. On 3/10/21 at 2:40 p.m., the UMLPN #6 stated she and other nurses can describe wounds and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #8 worked four days later on 3/3/21 with the same measurements, but the woundbed had deteriorated with 100% slough (unstageable due to inability to visualize woundbed to Stage the wound) with a concave base. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The first documentation of the right heel was dated 3/4/21 as 1.0 cm x 1.4 cm and 0.1 depth with no drainage and periwound appearance pink. Treatment was to cleanse diabetic ulcer to right heel with normal saline, apply wound gel and cover with a dry dressing. On 3/10/21 at 2:40 p.m., UMLPN #6 stated the right heel did not look like it did on 3/11/21, but I am thinking now this maybe a Stage II. She documented the following: Assessed resident's right heel and performed dressing change to heel. Since assessment one day prior, diabetic ulceration is larger by 0.3 (in length) towards bony prominence, with heel red and soft, indicating pressure involvement. Bilateral legs with noted pitting [CONDITION(S)] above sock line that also wasn't present with previous assessment. Larger socks applied after dressing change. MD was notified and treatment to continue as ordered .Area remains a diabetic ulceration, but is exacerbated by pressure indicated by the heel being soft and red .Resident was asked to keep shoes off for a couple of days. Resident agreed. On 3/12/21 at 10:20 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON). They stated the resident requested a new cushion for her wheelchair and they were sure she received one recently from the Occupational Therapist (OT). They also stated that the resident preferred to stay up in her wheelchair, but thought she was able to reposition herself, which was the opposite of the MDS assessment, care plan and the resident's statements. Additionally, the resident stated she was unable to reposition herself in the wheelchair without staff assistance. The DON stated UMLPN#6 said the appearance of the right heel on 3/11/21 changed from its appearance on 3/10/21 and that she was considering wound to be a Stage II at the recommendation of the surveyor. It was shared with the Administrator and the DON that no recommendations were given to the nursing staff and that UMLPN#6 and LPN#8 were vacillating back and forth as to whether to continue to assess the right heel ulcer origination as diabetic or pressure from the resident's shoes, exacerbated by [CONDITION(S)]. The DON stated she did not know what LPN#8 was referring to using the word divit to describe the heel wound. On 3/12/21 at 12:05 p.m., this surveyor and the Administrator went to the resident's room to check out the wheelchair cushion. The Administrator examined the condition of the cushion and stated, This cannot be the new cushion, torn and worn on the edges. Maybe the CNA placed the new one in another resident's chair. Without any prompting, Resident #64 voluntarily stated, I thought I was getting a new cushion. This one dips so much in center. The Administrator also recognized the resident's right leg [CONDITION(S)]. The resident stated she kept her shoes off because of the swelling unless she had to go out of her room. On 3/12/21 at approximately 2:50 p.m., the Administrator, DON and OT stated there was nothing wrong with the original cushion, but it was replaced because the resident felt it was worn out. The OT stated she examined the resident's cushion and said, I looked at the cushion that you all saw and it did not look like that when I gave it to her on 3/1/21. It was falling apart, so I took that one off and gave her another one. Maybe because the resident is incontinent, it bubbled and started to shred like that from urine. Also, these cushions are used and are kept outside in our storage unit, which makes them exposed to different temperature and atmospheric conditions. The OT stated there was nothing wrong with the resident's original cushion. OT presented the resident's original *Vive cushion, opened it and stated that it was 1-1/2 inch foam around to equal 3 inches, 16 x 18 cushion with gel. The cushion dipped in the middle and the gel was no longer expanded, but flattened. She stated subsequent cushions for the resident were similar with same type gel insert. *The following information was accessed on 3/15/21 from the Vive website (dated 2021) https://www.vivehealth.com/products/wheelchair-cushions-gel Effective Support: With a gel core, premium foam layer, a waterproof seal and topped off with a luxuriously soft cover, the 3 thick cushion will relieve back and tailbone pain from sciatica and other conditions. Distribute pressure evenly: The liquid gel core redistributes your weight away from high pressure areas like the tailbone and the coccyx where painful sores could develop. Supportive height quality foam: The premium foam layer will not flatten under your weight so that you will sit comfortably day after day. On 3/12/21 at 3:30 p.m., Resident #64 was observed in bed and a smaller cushion, with gaps on each side, was in the seat of the wheelchair that did not conform to the wheelchair and was sunken in the middle. The resident stated she just laid down and I have not had a chance to see if this one is better. On 3/12/21 at approximately 3:40 p.m., during debriefing with the Administrator, DON and Regional Corporate Nurse they stated the resident preferred to sit up in the wheelchair instead of getting back into the bed despite encouragement by the staff in case her husband visits or calls. They said an air mattress overlay was placed on the bed 3/9/21 and an air mattress replacement ordered. They reiterated that the initial wheelchair cushion 8/17/20 was traded out for another cushion at resident's request for more comfortable cushion on 3/1/21, and replaced again on 3/12/21 due to the recently issued cushion falling apart, however, all cushions were used cushions. They also restated they thought the resident was able to reposition herself, but would encourage more off-loading to bed. Select a seat and seating support surface that meets the individual's need for pressure redistribution with consideration to body size and configuration, effects of posture and deformity on pressure distribution, mobility and lifestyle needs (information retrieved on 3/15/21 from document Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 24, 2019). The following information was obtained on 3/15/21 from an article dated 2014 https://www.ncbi.nlm.nih.gov/books/NBK 6/ Heel pressure ulcers are localized injury to the heel as result of pressure sometimes in association with other factors. The heel is at the back of the foot, extending from the Achilles tendon around the plantar surface, it covers the apex of the calcaneum bone. It is a common site for pressure ulcer development. The lower limb can be subject to disease processes such as ischemia, [CONDITION(S)], structural changes (due to fractures or bone disorders) and [CONDITION(S)], all of which affect the development and healing of heel pressure ulcers. Prevention is key, but once a heel pressure ulcer has developed, pressure must be relieved from the heels to prevent further damage.

Based on observations, staff interviews and facility documentation review the facility staff failed to remove expired medication from 1 of 6 medication carts (A-Wing). The findings included: On [DATE] at 9:02 a.m., during a medication pass observation outside of room [ROOM NUMBER]-B on A Wing, Licensed Practical Nurse (LPN) #1 was observed pouring 2 tablets in medication cup from a bottle labeled [MEDICATION(S)] 5 gr (Grain) - 325 mg. (Milligram). Per inspection of the bottle it was observed that ,d+[DATE] was written in black ink on the bottle cap. When asked what ,d+[DATE] indicated, LPN #1 stated, This is when we opened it. Per further inspection of bottle an expiration date of ,d+[DATE] and Lot number 7 was observed. When asked what do you check for when preparing to give medications, LPN #1 stated, Check the name, correct dose and expiration date. When asked what is the expiration date on the bottle, LPN #1 stated, ,d+[DATE]. When asked if the medication was expired, LPN #1 stated, Yes. LPN #1 removed the [MEDICATION(S)] tablets from the medication cup. LPN #1 stated, I'm not going to give the [MEDICATION(S)] to the resident. When asked should you give expired medication to a resident, LPN #1 stated, No ma ' am. When asked what is the process when a medication is expired and you do not administer, LPN #1 stated, I will check to see if there is some more in the store room and give. On [DATE] at approximately 12:30 p.m., a copy of the Administration of Medication Policy and Procedure was requested. On [DATE] at approximately 2:00 p.m., a copy of the facility policy, Disposal/Destruction of Expired or Discontinued Medication, was received. The Director of Nursing was made aware of the finding during a briefing on [DATE] at approximately 3:00 p.m. When asked what are your expectations of nurses when administering medications, Director of Nursing stated, To check the expiration date. No further information was provided. The facility policy titled - Disposal/Destruction of Expired or Discontinue Medication Applicability: This policy 8.2 sets forth procedures relating to medication disposal and destruction. Procedure: 4. Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction.

Based on resident interview, family interview, staff interviews, and clinical record review, the facility's staff failed to act on replacing missing dentures after they were know not to be in the resident's possession for 1 of 41 residents (Resident 4), in the survey sample. The findings included: Resident #4 was originally admitted to the facility 11/5/2017 and had never been discharged . The resident has never been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/10/20 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as moderately impaired for daily decision making. In section G (Physical functioning) the resident was coded as requiring extensive assistance of one person with bathing and dressing, limited assistance of one person, with bed mobility, transfers, and personal hygiene, supervision with one person assistance with walking in room, supervision after set-up with eating. Section L Oral/Dental was coded for no dental concerns. On 3/10/20, at approximately 2:10 p.m., an interview was conducted with Resident #4. Resident #4 stated I have one concern, my weight loss; My daughter stated she doesn't want me to loose anymore weight. The resident further stated I try to eat and I eat what I want but I'm still losing weight. Resident #4 denied swallowing or chewing problems but she had no teeth and or dentures (upper or lowers) currently in use. The resident stated she had dentures but they were lost a while ago. The resident also stated she would like to have replacement dentures but she didn't know how to get them. On 3/10/20, at approximately 8:10 p.m., an interview was conducted with Resident #4's daughter. The daughter stated her mother's lower denture plate had been missing since shortly after receiving a replacement set of dentures and staff was aware of it because an attempt was made to modify the consistency of her foods to accommodate for the loss of the lower dentures. Resident #4 further stated the chopped food diet was not well received by the resident and she began to eat less therefore; the staff changed the diet back to regular texture but still no arrangements were made to replace the second case of missing dentures. During the midday meal on 3/11/20, the resident consumed only a magic cup and a chocolate ice cream sundae. The soup, sliced beef with gravy, mashed potatoes and vegetable were not touched. An interview was conducted with Licensed Practical Nurse (LPN) #3 on 3/11/21 at approximately 12:10 p.m. LPN #3 stated some residents has an order on the Medication/Treatment record to apply and remove appendages such as dentures, hearing aids, eyeglasses but Resident #4 wasn't one of those residents. LPN #3 further stated Resident #4 managed her own and was known to leave her dentures on the meal tray or hide them from herself but she would have the assigned Certified Nursing Assistant (CNA) assist the resident to locate the missing teeth. An interview was conducted with the Social Worker on 3/11/2021, at approximately 1:25 p.m. The Social Worker stated she had not been alerted that Resident #4's dentures were missing but she would follow-up on the concern. After speaking to the resident's daughter and staff the Social Worker reported she arranged for a dental consult and notified the staff to arrange transportation for replacement dentures. The Social Worker stated the resident's daughter stated the dentist the resident saw previously is no longer in practice in the area and she had no preference or recommendation of which dentist to use, asking that the facility set up an appointment with whoever other residents in the facility typically sees. The above information was shared with the Administrator and Director of Nursing on 3/12/21 at approximately 1:45 p.m. The Director of Nursing stated she had recently spoken with Resident #4's daughter and she didn't mention the resident's dentures were missing.

574-C The facility staff failed to ensure postings of State Agencies were in large enough font, positioned well and accessible to facility residents. FACILITY Resident Council 03/11/21 11:39 AM Resident council was at 10:30 am and voiced concerns about missing clothing, snacks at night are not substantive even for the diabetic-I went to the A Wing refrigerator and found crackers and nabs- and [NAME] WARD, LPN stated that snacks are given with their meals at 5:00 p.m., but she works 7:00 am to 7:00 p.m I will tell [NAME] and see if she can check the kitchen. The diabetic in the group (Vera [NAME] on B wing said she gets crackers and has awaken sweating due to low blood sugar. The President stated crackers with no drink-would like fruit, yogurt, or something else. They do not offer?? Been having Council meetings even during the Pandemic. No aware of survey results-where located, not aware on Ombudsman or our office if need to contact. The Administrator does not comeback to tell you about missing items investigation, it is the employee from the laundry that says, We could not find it. The facility staff failed to ensure State office numbers to include Office of Licensure and Certification (OLC) were posted in a conspicuous area, appropriately positioned and with a font that is large enough to be read by residents.

Based on observations, clinical record review, staff and resident interviews, the facility staff failed to provide personal hygiene to include full body showers and or whirlpools with hair washing for 4 of 41 residents (#64, #52, #19 and #53) in the survey sample. The findings include: 1. Resident #64 was not receiving personal hygiene to include showers and hair shampoos since 12/25/20. Resident #64 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) assessment was an Annual dated 1/25/21 and coded Resident #64 with a 15 out of a possible score of 15 which indicated the resident was intact with the skills needed for daily decision making. The MDS assessed the resident to not reject care. The resident was assessed totally dependent on one staff for dressing, personal hygiene and bathing. Resident #64 required extensive assistance of one staff for bed mobility, transfer, eating and toilet use. The resident was coded not steady and only able to stabilize herself with staff assistance for moving from seated position, moving off the toilet and surface to surface transfer. The resident was assessed impaired on both sides of upper extremity in range of motion. The resident was assessed to use a wheelchair. Resident #64 was assessed frequently incontinent of bowel and bladder. The care plan dated 8/23/19 identified self-care deficit and that Resident #64 required assistance with Activities of Daily Living (ADL). The goal set by the staff was that the resident's ADL needs would be met. Some of the approaches the staff would implement to accomplish this goal included assist with ADLs, dressing, grooming, toileting, feeding and oral care. On 3/10/21 at 12:15 p.m., Resident #64 was observed in her wheelchair in her room. She stated she could not remember the last time she had a shower and her hair washed, It has been months. I only get hand baths. She stated even though she wore a wig, she still would love to have her hair washed and it had been months. Strands of her natural hair was observed at the nape of her neck from under her wig. There was no record of showers or documentation that the resident's hair had been washed since 12/25/20 when droplet precautions for COVID-19 were discontinued. On 3/12/21 at 10:20 a.m., the Director of Nursing (DON) presented the aforementioned documentation that indicated the resident was off transmission based precautions on 12/25/20, thus the aides could have restarted showers for Resident #64. On 3/12/21 at 12:05 p.m., this surveyor and the Administrator went to the resident's room at which time, without any prompting, Resident #64 asked the Administrator if she could make sure her hair was washed and showers resumed. The Administrator stated as long as a resident was not on transmission based precautions, they could be given a shower and their hair shampooed. She reassured the resident her showers and shampoos would resume. On 3/12/21 at 3:40 p.m., during the debriefing with the Administrator, Director of Nursing (DON) and the Regional Corporate Nurse, no further information was provided prior to survey exit. 2. Resident #52 was not receiving personal hygiene to include showers and hair shampoos since 12/22/20. Resident #52 was originally admitted to the nursing facility on 10/2/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) assessment was dated 1/12/21 and coded Resident #52 with a 15 out of a possible score of 15 which indicated the resident was intact with the skills needed for daily decision making. The MDS assessed the resident to not reject care. The resident was assessed to need supervision and support from one staff for bathing and personal hygiene. She was coded occasionally incontinent of urine and frequently incontinent of bowel. The care plan dated 1/27/21 identified the resident with ADL self care performance deficit related to limited mobility and required assistance with ADLs. The goal set by the staff for the resident included the resident would maintain her current level of function and resident needs would be met. Some of the approaches the staff would implement to accomplish this goal included assist with ADLs, dressing, grooming, toileting, feeding and oral care. On 3/10/21 at 12:15 p.m., Resident #52 was observed in her wheelchair in her room. She stated she was told because of the Pandemic only wash-ups could be done and once she was set up, she washed herself, but would love to restart her whirlpool and have her hair washed. She stated, I would feel so much better if I could get my whirlpools back and I would love my head washed. Even though I am bald on top, my head is a part of my body and it should be washed too. She wore a wig and gray hair was visible around the edges of the wig. There was no record of showers or documentation that the resident's hair had been washed since 12/22/20 when transmission based precautions were discontinued. On 3/12/21 at 10:20 a.m., the Director of Nursing (DON) presented the aforementioned documentation that indicated the resident was off transmission based precautions on 12/22/20, thus the aides could have restarted whirlpools for Resident #52. On 3/12/21 at 12:05 p.m., this surveyor and the Administrator went to the resident's room at which time, without any prompting, Resident #52 asked the Administrator if she could make sure her hair was washed and whirlpools resumed. The Administrator stated as long as a resident was not on transmission based precautions, they could be given a shower/whirlpool and their hair shampooed. Resident #52 asked the Administrator if she was sure she could have her whirlpools and her hair washed. The resident wanted to know if she needed to provide the hair shampoo. The Administrator reassured the resident that the facility would provide shampoo and her whirlpools would resume. On 3/12/21 at 3:40 p.m., during the debriefing with the Administrator, Director of Nursing (DON) and the Regional Corporate Nurse, no further information was provided prior to survey exit. 3. Resident #19 was not receiving personal hygiene to include showers since 2/18/21. Resident #19 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #19's Minimum Data Set (an annual assessment) with an Assessment Reference Date of 11/07/20 coded Resident #19 with a BIMS (Brief Interview for Mental Status) score of 13 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #19 as requiring supervision of 1 person for bed mobility, and eating. Limited assistance of 1 person with dressing. Extensive assistance of 1 for personal hygiene. 1 person physical assistance with bathing. Independence with transfers. Careplan: The careplan reads that Resident #19 has a Self care deficit. -refuses teds at times, refuses showers. Goals: Residents needs will be met with regard to adl's through next review. Interventions: Break tasks down so that adl's are easier for resident to perform and encourage resident participation while performing adl's. During the tour on 03/11/21 9:39 AM Resident #19 was observed lying in bed. She was asked if she was taking baths and what days were her showers scheduled. She stated, They don't give me any showers. I want to start taking showers. CNA (Certified Nurse's Aide) #3 walked in. Resident #19 stated I feel like I have sand in my socks. CNA #3 replied, I'm getting ready to give you care now. What do you want a bath or shower. Resident #19 replied. A shower. A review of the B-Wing shower book on 3/11/21 showed Resident #19, should receive showers on Monday and Thursdays during the 7A-3P Shower List. The shower list reads: Every resident is to be offered a shower, if they refuse, put refused. This is completed daily. The shower list shows that Resident #19 did not receive any showers for the months of February and March. Resident should have received showers on the following days during 7A-3P shift. The January shower list is not available per LPN #2. The list for February was only available from 2/18/21 - 2/27/21. Scheduled days were Mondays and Thursdays 7 AM-3 PM no showers were given on the following scheduled dates: 2/18, 2/22 and 2/25, 3/01, 3/04 and 3/08/21. On 3/11/21 at 9:53 AM an interview was conducted with LPN (Licensed Practical Nurse) #2 concerning Resident not receiving any showers. She stated, The DON (Director of Nursing) said everyone that has been vaccinated on this unit can receive a shower. On 03/11/21 at 10:23 AM CNA #3 was seen transporting resident #19 via wheel chair to the shower room. On 3/12/21 at 10:15 am an interview was conducted with Resident #19 concerning her getting her scheduled shower today. She was asked how did taking the shower make her feel. She stated, Wonderful. I haven't had a shower in a while. I get a bed bath everyday. My feet are feeling better today. No sand but sore today. 4. Resident #53 was not receiving personal hygiene to include showers and hair shampoos since 2/20/21. Resident #53 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #53's Minimum Data Set (an Admission assessment) with an Assessment Reference Date of 1/17/21 coded Resident #53 with a BIMS (Brief Interview for Mental Status) score of 3 indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #53 as requiring extensive assistance of 1 person with dressing, and personal hygiene. Requires extensive assistance of 2 persons for bed mobility. Requires 1 person physical assistance with eating. Requires total dependence with bathing. On 03/11/21 at 10:12 AM Resident #53 was seen ambulating in the hallway with OSM #2 (Physical Therapist) her hair appeared matted and uncombed. A review of the B-Wing shower book shows Resident #53, should receive showers on Wednesdays during the 7A-3P Shower List. The shower list reads: Every resident is to be offered a shower, if they refuse, put refused. This is completed daily. The shower list shows that Resident #53 did not receive any showers for the months of February and March. Resident should have received showers on the following days during 7A-3P shift on Wednesday and Saturdays. The January shower list is not available per LPN #2. The list for February was only available from 2/18/21 - 2/27/21. Scheduled shower days were Wednesdays and Saturdays 7 AM-3 PM no showers were given on the following dates: 2/20, 2/24, 2/27, 3/03, 3/06, 3/10/21. Careplan: Reads that Resident #53 has a self-care deficit relating to disease processes and needs assistance with ADLs (Activity of Daily Living). Goal: Resident needs will be met. Interventions: Assist with activities of daily living, dressing, grooming, toileting, feeding, oral care. On 03/12/21 at 9:49 AM an interview was conducted with LPN #2 concerning Resident #53 receiving showers on Wednesday and Saturdays. She stated, It should be initialed in the book when completed. Lately they haven't been documenting on the ADL sheets. On 03/12/21 at 9:55 AM an interview was conducted with CNA #6 concerning Resident #53. She stated, I don't have her most of the time. She's not my normal. Showers are given on 3 different shifts. If a resident refuses showers we tell the nurse and she documents in the chart and we put an R (for Refusal) and initial in the book. On 3/12/21 at 9:59 AM an interview was conducted with LPN #3 concerning Residents not receiving showers. She stated, No one told me they refused showers. When they were on isolation they weren't allowed to leave their rooms. Resident #53 was on isolation on the C unit for 3 weeks. She was admitted on [DATE] to 1/26/21 and came to this unit on 1-26-21. On 3/12/21 at 10:12 AM an interview was conducted with Resident #53 concerning her receiving showers. She stated, I don't think I can get showers because of this thing (pointing to peg tube). My hair itches. Can you say something to them? It (her hair) hasn't been washed since Christmas. On 03/11/21 at 12:34 PM the DON was interviewed concerning Residents not receiving their showers. She stated, Unless the person is on isolation people should be getting showers. On 3/11/21 at 3:00 PM a phone call was made to Resident's daughter to request a resident representative interview. She stated that her sister was the RP (Responsible Party) for her mom but they both were concerned that their mother was not receiving showers or getting her hair washed. The daughter was reassured by surveyor that the issue would be investigated. On 3/12/21 at 12:30 PM an interview was conducted with CNA #3 concerning resident receiving showers. She stated, We had COVID-19 and they (Residents) were on isolation. Most of the time they do get a shower if they want it. We have shampoo bags. We wash their hair as often as needed. I will ask if you want your shower I ask them if they want their hair washed. I will use the shower cap. Policy: Resident Bath/Showering/Scheduling Policy. Effective: 1/01/2008. Last Revision Date: 02/01/2021. Reads: Residents will be bathed or showered according to their preferences in order to maintain healthy hygiene and skin condition. (A). Each Resident will be asked about his/her bathing preference upon admission (type of bath, preferred days and times). (B). Each resident will be scheduled to receive bathing a minimum of two times per week unless they prefer less frequent baths or state regulation requires more frequent bathing. (C). The facility will develop and maintain a bathing/shower schedule for each unit. (D). At the beginning of the shift the Charge Nurse will review the bathing schedule for that day and shift with the nursing assistants. (E). When the bath or shower is complete the nursing assistant will document the activity on the shower sheet or in point of care section of the electronic record. (G). A shower sheet will be completed for each bath/shower given. (H). If the bath/shower cannot be given or the resident refuses, the nursing assistant will promptly report this to the Charge Nurse. Policy: Morning Care/AM Care. Effective: January 2011. Last Revision Date: 6/15/2020. Morning Care will be offered each day to promote resident comfort, cleanliness, grooming and general wellbeing. Residents who are capable of performing their own personal care are encouraged to do so but will be provided with setup assistance if needed. Showers and baths are scheduled three times weekly or more or less often according to resident preference. Procedure: Assemble supplies: Basin, soap/shampoo, comb/brush, lotion, oral care supplies, nail care supplies, linen, garments, incontinent supplies if needed. #5. Provide bath/shower as indicated. #13. Brush/comb hair. On 03/12/21 at 1:22 PM an interview was conducted with the DON and the Administrator concerning the above Residents not receiving their showers. No comments were made.

Based on a complaint investigation, observations, staff and resident interviews and facility documentation, the facility staff failed to accurately assess and provide effective pressure relief while in sitting in a wheelchair to prevent pressure ulcers for 1 of 41 residents (Resident #64) in the survey sample. The findings include: Resident #64 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) assessment was an Annual dated 1/25/21 and coded Resident #64 with a 15 out of a possible score of 15 which indicated the resident was intact with the skills needed for daily decision making. The MDS assessed the resident to not reject care. The resident was assessed totally dependent on one staff for dressing, personal hygiene and bathing. Resident #64 required extensive assistance of one staff for bed mobility, transfer, eating and toilet use. The resident was coded not steady and only able to stabilize herself with staff assistance for moving from seated position, moving off the toilet and surface to surface transfer. The resident was assessed impaired on both sides of upper extremity in range of motion. The resident was assessed to use a wheelchair. Resident #64 was assessed frequently incontinent of bowel and bladder. The resident was coded with weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was on a therapeutic, mechanically altered diet. The resident's height and weight was recorded as 5 ft. 3 in and 105 lbs. Based on the Braden Scale formal assessment instrument and clinical assessment, Resident #64 did not have any current pressure ulcers/injuries, but was coded at risk for them. The assessment indicated the resident had pressure reducing devices for the chair and bed, nutrition or hydration interventions and applications of ointments and medications other than feet for skin and ulcer/injury treatments. The care plan dated 8/23/19 to current identified that the resident was at risk for impaired skin integrity related to decreased mobility, incontinence, diabetes and cognition. The goal the staff set for the resident was that the area would show improvement and be free of signs and symptoms of infection. Some of the approaches the staff would take to accomplish this goal included elevate heels, monitor and report to physician redness, swelling, local warmth, tenderness, discharge and elevated temperature, nutritional status, skin prep per orders, turn and reposition as indicated and wheelchair cushion. Resident #64 was care planned for COVID-19 virus on 12/15/20 and droplet precautions/isolation ordered. On 3/10/21 at 12:15 p.m., Resident #64 was observed in her wheelchair, sitting on a black cushion. She possessed a constant tremor of both arms, hands, as well as facial twitches of eyes and lips. The condition of the cushion was not visible during this observation. The resident stated she had been up in the chair since around 9:30 a.m. The resident stated she got up in the morning and usually laid down and was changed before dinner. She stated the nursing staff did not routinely lift, stand or reposition her while she was in the chair. Certified Nursing Assistant (CNA) #8 placed the resident in bed at 4:00 p.m. for a rest before dinner. The cushion had a plastic cover and observed creased and dipped in the center with an obvious warped bubbled appearance rips along the edges. Sacral wound pressure ulcer observation: On 3/11/21 at 12:32 p.m., Licensed Practical Nurse (LPN) #8 (wound care nurse) accompanied by LPN #7 transferred Resident #64 to bed to provide treatment to a sacral pressure ulcer. The area was described by LPN 8 as a *Stage III with slough (slough is soft necrotic/dead tissue), .9 cm (centimeters) length by (x) .5 cm width. The wound was cleansed with normal saline followed by Santyl (topical debridement) and covered with a boarded dressing. LPN #8 stated she was the nurse to stage wounds due to her training and LPN #7 covered in her absence. LPN #8 also stated she performed wound care treatments on Wednesdays and Thursdays with the licensed nurse's to provide treatments the remaining days. LPN #8 said the physician took her description of wounds and recommendation for treatment, but if wounds require the physician to observe, she will either take a picture and send it to the physician or if necessary, he or she will come in. LPN #8 stated the sacral pressure ulcer was facility acquired and when asked about the etiology of the wound she responded, She got this pressure area from sitting up in her wheelchair too long, but she has a cushion. The resident spoke up and said, I thought I was going to get a new cushion, this one bends in the middle. The cushion was the same one as observed the previous day in the wheelchair. LPN #7, stated the resident's wheelchair cushion was called a non-specific cushion which indicated it was a basic wheelchair cushion. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *Stage III involves the full thickness of the skin and may extend into the subcutaneous tissue layer; granulation tissue and epibole (rolled wound edges) are often present. At this stage, there may be undermining and/or tunneling that makes the wound much larger than it may seem on the surface (Information retrieved on 3/15/21 from document Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 40, 2019). Right foot wound observation: The LPN #8, wound care nurse, and LPN #7 prepared to perform wound care to the right heel. LPN #7 proceeded to pull up Resident #64's right pant leg when she observed significantly greater swelling of the right leg/foot than the left, pitting [CONDITION(S)]. LPN 7 stated, (Resident #64's name) we have to take these socks off and find something looser. When the existing dressing was removed, an inflamed reddened area was observed on the resident's medial heel with an open area. The resident said she did not feel anything was there. LPN #8 did not hesitate to state the right heel was a diabetic ulcer and appeared to be a divit on the sole of the resident's foot the previous day (3/10/21). She said a divit was like an open dent and it was first identified on 3/4/21, but today I may be leaning more towards a *Stage II because it is more towards the bony prominence? It could still be a diabetic ulcer. She stated they needed to keep pressure off the area and would have the resident leave her shoes off for a few days. They stated, Her diabetic shoes have been ordered which will give her more room and avoid any pressure to her heels. LPN#8 was asked to provide professional documentation to support that this area on the resident's bony prominence of the medial heel was a diabetic ulcer and not the result of [CONDITION(S)] and pressure from a malfitting tight shoe. The documentation was not provided prior to survey exit. *A Stage II is a Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed without slough. May also present as an intact or open/ruptured serum-filled blister (information retrieved on 3/15/21 from document Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 39, 2019). The resident was observed back up in her wheelchair on 3/11/21 at 1:15 p.m. for the lunch meal. The shoes remained off. On 3/11/21 at 2:38 p.m., Resident #64 stated she thought she got a new cushion, but the one she had was dipped in the center and it was not what I thought I was going to get. She said she was not able to push up on the arms of the wheelchair to reposition her lower body and buttocks without help, but the staff did not reposition her while in the wheelchair and that was why she wanted a more comfortable cushion. The resident was observed in the wheelchair at 4:05 p.m. The first documentation by the Unit Manager (UM) LPN #6 of the sacral wound was dated 2/27/21 as 1 cm (length) by 1 cm (width) and 0.1 cm depth, no drainage, pink wound bed, no odor, pink periwound and in house acquired. The physician was notified and treatment included [MEDICATION(S)] dressing every three days and that the resident was made aware of small open area on bony area of coccyx. On 3/10/21 at 2:40 p.m., the UMLPN #6 stated she and other nurses can describe wounds and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #8 worked four days later on 3/3/21 with the same measurements, but the woundbed had deteriorated with 100% slough (unstageable due to inability to visualize woundbed to Stage the wound) with a concave base. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The first documentation of the right heel was dated 3/4/21 as 1.0 cm x 1.4 cm and 0.1 depth with no drainage and periwound appearance pink. Treatment was to cleanse diabetic ulcer to right heel with normal saline, apply wound gel and cover with a dry dressing. On 3/10/21 at 2:40 p.m., UMLPN #6 stated the right heel did not look like it did on 3/11/21, but I am thinking now this maybe a Stage II. She documented the following: Assessed resident's right heel and performed dressing change to heel. Since assessment one day prior, diabetic ulceration is larger by 0.3 (in length) towards bony prominence, with heel red and soft, indicating pressure involvement. Bilateral legs with noted pitting [CONDITION(S)] above sock line that also wasn't present with previous assessment. Larger socks applied after dressing change. MD was notified and treatment to continue as ordered .Area remains a diabetic ulceration, but is exacerbated by pressure indicated by the heel being soft and red .Resident was asked to keep shoes off for a couple of days. Resident agreed. On 3/12/21 at 10:20 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON). They stated the resident requested a new cushion for her wheelchair and they were sure she received one recently from the Occupational Therapist (OT). They also stated that the resident preferred to stay up in her wheelchair, but thought she was able to reposition herself, which was the opposite of the MDS assessment, care plan and the resident's statements. Additionally, the resident stated she was unable to reposition herself in the wheelchair without staff assistance. The DON stated UMLPN#6 said the appearance of the right heel on 3/11/21 changed from its appearance on 3/10/21 and that she was considering wound to be a Stage II at the recommendation of the surveyor. It was shared with the Administrator and the DON that no recommendations were given to the nursing staff and that UMLPN#6 and LPN#8 were vacillating back and forth as to whether to continue to assess the right heel ulcer origination as diabetic or pressure from the resident's shoes, exacerbated by [CONDITION(S)]. The DON stated she did not know what LPN#8 was referring to using the word divit to describe the heel wound. On 3/12/21 at 12:05 p.m., this surveyor and the Administrator went to the resident's room to check out the wheelchair cushion. The Administrator examined the condition of the cushion and stated, This cannot be the new cushion, torn and worn on the edges. Maybe the CNA placed the new one in another resident's chair. Without any prompting, Resident #64 voluntarily stated, I thought I was getting a new cushion. This one dips so much in center. The Administrator also recognized the resident's right leg [CONDITION(S)]. The resident stated she kept her shoes off because of the swelling unless she had to go out of her room. On 3/12/21 at approximately 2:50 p.m., the Administrator, DON and OT stated there was nothing wrong with the original cushion, but it was replaced because the resident felt it was worn out. The OT stated she examined the resident's cushion and said, I looked at the cushion that you all saw and it did not look like that when I gave it to her on 3/1/21. It was falling apart, so I took that one off and gave her another one. Maybe because the resident is incontinent, it bubbled and started to shred like that from urine. Also, these cushions are used and are kept outside in our storage unit, which makes them exposed to different temperature and atmospheric conditions. The OT stated there was nothing wrong with the resident's original cushion. OT presented the resident's original *Vive cushion, opened it and stated that it was 1-1/2 inch foam around to equal 3 inches, 16 x 18 cushion with gel. The cushion dipped in the middle and the gel was no longer expanded, but flattened. She stated subsequent cushions for the resident were similar with same type gel insert. *The following information was accessed on 3/15/21 from the Vive website (dated 2021) https://www.vivehealth.com/products/wheelchair-cushions-gel Effective Support: With a gel core, premium foam layer, a waterproof seal and topped off with a luxuriously soft cover, the 3 thick cushion will relieve back and tailbone pain from sciatica and other conditions. Distribute pressure evenly: The liquid gel core redistributes your weight away from high pressure areas like the tailbone and the coccyx where painful sores could develop. Supportive height quality foam: The premium foam layer will not flatten under your weight so that you will sit comfortably day after day. On 3/12/21 at 3:30 p.m., Resident #64 was observed in bed and a smaller cushion, with gaps on each side, was in the seat of the wheelchair that did not conform to the wheelchair and was sunken in the middle. The resident stated she just laid down and I have not had a chance to see if this one is better. On 3/12/21 at approximately 3:40 p.m., during debriefing with the Administrator, DON and Regional Corporate Nurse they stated the resident preferred to sit up in the wheelchair instead of getting back into the bed despite encouragement by the staff in case her husband visits or calls. They said an air mattress overlay was placed on the bed 3/9/21 and an air mattress replacement ordered. They reiterated that the initial wheelchair cushion 8/17/20 was traded out for another cushion at resident's request for more comfortable cushion on 3/1/21, and replaced again on 3/12/21 due to the recently issued cushion falling apart, however, all cushions were used cushions. They also restated they thought the resident was able to reposition herself, but would encourage more off-loading to bed. Select a seat and seating support surface that meets the individual's need for pressure redistribution with consideration to body size and configuration, effects of posture and deformity on pressure distribution, mobility and lifestyle needs (information retrieved on 3/15/21 from document Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 24, 2019). The following information was obtained on 3/15/21 from an article dated 2014 https://www.ncbi.nlm.nih.gov/books/NBK 6/ Heel pressure ulcers are localized injury to the heel as result of pressure sometimes in association with other factors. The heel is at the back of the foot, extending from the Achilles tendon around the plantar surface, it covers the apex of the calcaneum bone. It is a common site for pressure ulcer development. The lower limb can be subject to disease processes such as ischemia, [CONDITION(S)], structural changes (due to fractures or bone disorders) and [CONDITION(S)], all of which affect the development and healing of heel pressure ulcers. Prevention is key, but once a heel pressure ulcer has developed, pressure must be relieved from the heels to prevent further damage.

Based on observations, staff interviews and facility documentation review the facility staff failed to remove expired medication from 1 of 6 medication carts (A-Wing). The findings included: On [DATE] at 9:02 a.m., during a medication pass observation outside of room [ROOM NUMBER]-B on A Wing, Licensed Practical Nurse (LPN) #1 was observed pouring 2 tablets in medication cup from a bottle labeled [MEDICATION(S)] 5 gr (Grain) - 325 mg. (Milligram). Per inspection of the bottle it was observed that ,d+[DATE] was written in black ink on the bottle cap. When asked what ,d+[DATE] indicated, LPN #1 stated, This is when we opened it. Per further inspection of bottle an expiration date of ,d+[DATE] and Lot number 7 was observed. When asked what do you check for when preparing to give medications, LPN #1 stated, Check the name, correct dose and expiration date. When asked what is the expiration date on the bottle, LPN #1 stated, ,d+[DATE]. When asked if the medication was expired, LPN #1 stated, Yes. LPN #1 removed the [MEDICATION(S)] tablets from the medication cup. LPN #1 stated, I'm not going to give the [MEDICATION(S)] to the resident. When asked should you give expired medication to a resident, LPN #1 stated, No ma ' am. When asked what is the process when a medication is expired and you do not administer, LPN #1 stated, I will check to see if there is some more in the store room and give. On [DATE] at approximately 12:30 p.m., a copy of the Administration of Medication Policy and Procedure was requested. On [DATE] at approximately 2:00 p.m., a copy of the facility policy, Disposal/Destruction of Expired or Discontinued Medication, was received. The Director of Nursing was made aware of the finding during a briefing on [DATE] at approximately 3:00 p.m. When asked what are your expectations of nurses when administering medications, Director of Nursing stated, To check the expiration date. No further information was provided. The facility policy titled - Disposal/Destruction of Expired or Discontinue Medication Applicability: This policy 8.2 sets forth procedures relating to medication disposal and destruction. Procedure: 4. Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction.

Based on a complaint investigation, staff interviews, medical record review, facility document review, hospital record review, and emergency medical services record review, the facility staff failed to provide the assessed feeding need of supervision with one person physical support for 1 resident during lunch on [DATE] that resulted in the resident choking on a piece of chicken, which constitutes harm for 1 of 4 residents in the survey sample, Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a Quarterly with an Assessment Reference Date (ARD) of [DATE]. The Brief Interview for Mental Status was coded as a 7 out of a possible 15 indicating Resident #1 was severely cognitively impaired. Under Section G0110 Activities of Daily Living (ADL) Assistance; (H.) Eating, Resident #1 was coded under 1. ADL Self Support as a 1=Supervision-oversight, encouragement or cueing. Under 2. ADL Support Provided Resident #1 was coded as 2=One person physical assist. Under Section G0400 Functional Limitation in Range of Motion (Code for limitation that interfered with daily functions or placed resident at risk of injury); A. Upper extremity (shoulder, elbow, wrist, hand) Resident #1 was coded as 2=Impairment on both sides. The following Minimum Data Sets for Resident #1 were reviewed and are documented in part, as follows: Quarterly with an Assessment Reference Date (ARD) of [DATE]. Under Section G0110 Activities of Daily Living (ADL) Assistance; (H.) Eating, Resident #1 was coded under 1. ADL Self Support as a 1=Supervision-oversight, encouragement or cueing. Under 2. ADL Support Provided Resident #1 was coded as 2=One person physical assist. Under Section G0400 Functional Limitation in Range of Motion (Code for limitation that interfered with daily functions or placed resident at risk of injury); A. Upper extremity (shoulder, elbow, wrist, hand) Resident #1 was coded as 2=Impairment on both sides. Quarterly with an Assessment Reference Date (ARD) of [DATE]. Under Section G0110 Activities of Daily Living (ADL) Assistance; (H.) Eating, Resident #1 was coded under 1. ADL Self Support as a 3=Extensive assistance Under 2. ADL Support Provided Resident #1 was coded as 2=One person physical assist. Under Section G0400 Functional Limitation in Range of Motion (Code for limitation that interfered with daily functions or placed resident at risk of injury); A. Upper extremity (shoulder, elbow, wrist, hand) Resident #1 was coded as 2=Impairment on both sides. Comprehensive Annual with an Assessment Reference Date (ARD) of [DATE]. Under Section G0110 Activities of Daily Living (ADL) Assistance; (H.) Eating, Resident #1 was coded under 1. ADL Self Support as a 1=Supervision-oversight, encouragement or cueing. Under 2. ADL Support Provided Resident #1 was coded as 2=One person physical assist. Under Section G0400 Functional Limitation in Range of Motion (Code for limitation that interfered with daily functions or placed resident at risk of injury); A. Upper extremity (shoulder, elbow, wrist, hand) Resident #1 was coded as 2=Impairment on both sides. Resident #1's Comprehensive Care Plan with the last facility review being [DATE] was reviewed and is documented in part, as follows: Focus: Name (Resident #1) has self-care deficit and requires assistance with ADL's related to mobility status. Date Initiated: [DATE] Revision on: [DATE] Goal: Resident needs will be met. Interventions: Assist with activities of daily living, dressing, grooming, toileting, feeding, oral care. Date Initiated: [DATE] Focus: Name (Resident #1) has a potential for nutritional problem and dehydration/fluid intake issues related to po (by mouth) intake. Date Initiated: [DATE] Revision on: [DATE] Goal: The resident will maintain adequate nutritional status. Interventions: Assess/document/report to Nursing/MD (medical doctor) PRN (as needed) for s/s (signs and/or symptoms) of dysphagia (difficulty swallowing): Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals, etc. Date Initiated: [DATE] On [DATE] at 1:30 P.M. a phone interview was conducted with the facility MDS Coordinator RN (Registered Nurse) #1 regarding Resident #1. MDS Coordinator RN #1 was asked to review Resident #1's Quarterly MDS with the ARD date of [DATE] under Section G0110 Activities of Daily Living (ADL) Assistance; (H.) Eating and to tell the Surveyor how Resident #1 was coded. MDS Coordinator RN #1 stated, The resident was coded as requiring supervision with one person physical support ,[DATE]. This surveyor asked MDS Coordinator RN #1 to explain what that meant. MDS Coordinator RN #1 stated, She would need one person supervising her, someone would need to be with her the whole time she was eating . MDS Coordinator RN #1 was asked if Resident #1 was alone eating lunch on [DATE] and choked would that be considered as having supervision with one person physical support. MDS Coordinator RN #1 stated, No, if she was alone she was not being supervised. Resident #1 current Physician order [REDACTED]. Dietary-Diet: Cardiac/LCS (low concentrated sweets) diet Regular texture, Thin consistency, NO ADDED SALT Order Date: [DATE] Resident #1's facility Dietary Preference Sheet was reviewed and is documented in part, as follows: Lunch: Dining Location: Eats In Room Diet Order: Regular, Cardiac, LCS Alerts: Dislikes: >Chicken (Bone-In Chicken Breast), >Coffee, >Carrots (Unless in soup) The facility's Menu for lunch on [DATE] was reviewed and is documented in part, as follows: Resident's Choice: Fried Chicken, Macaroni and Cheese, Lima Beans, Dinner Roll, Margarine, Cream Pie, Beverage of Choice. Resident #1's Progress notes on [DATE] were reviewed and are documented in part, as follows: [DATE] 14:36 P.M. SBAR (Situation-Background-Assessment-Recommendation) Summary for Providers completed by LPN (Licensed Practical Nurse) #1. Situation: The Change in Condition reported on this Evaluation are/were: Loss of consciousness ([MEDICAL CONDITION]) Shortness of breath. At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure: BP ,[DATE]-[DATE] 16:01 Position: Sitting right/arm Pulse: P 81-[DATE] 16:01 Pulse Type: Regular RR(Respirations): R 18.0-[DATE] 14:38 Temperature: T 103.4-[DATE] 12:15 Route: Oral Weight: W 192.4lb (pounds)-[DATE] 14:17 Scale: Mechanical lift scale Pulse Oximetry: 02 (oxygen) 57%-[DATE] 16:03 Method: Oxygen via Mask Blood Glucose: BS 240.0-[DATE] 09:10 Outcomes of Physical Assessment: Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse). Functional Status Evaluation: No changes observed. Respiratory Status Evaluation: Labored or rapid breathing. Abnormal lung sounds (rales, rhonchi, wheezing). Cardiovascular Status Evaluation: (Blank) Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse). Nursing observations, evaluations, and recommendations are: Resident observed by staff in respiratory distress. Resident is DNR/CC (Do Not Resuscitate/Comfort Care). Mouth sweep produced piece of unchewed chicken. Staff suctioned excessive amount of mucous and phlegm from airway. Nebulizer administered, 02 increased to 5 liters via non rebreather, vs (vital signs) obtained ,[DATE]-101XXX,[DATE]. 02 sats. 57%. Family notified and stated to send resident to ER (emergency room ) for evaluation. Call placed to 911. EMS (Emergency Medical Services) in building to transport to ER. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send to ER for evaluation. [DATE] 15:50 P.M. Nursing Note: Resident observed by staff in respiratory distress. Resident is DNR/CC. Mouth sweep produced piece of unchewed chicken. Staff suctioned excessive amount of mucous and phlegm from airway. Nebulizer administered, 02 increased to 5 liters via non rebreather, vs obtained ,[DATE]-101XXX,[DATE]. 02 sats. 57%. Family notified and stated to send resident to ER for evaluation. Call placed to 911. EMS in building to transport to ER. [DATE] 15:54 P.M. Nursing Note: Received call from ER that resident expired. Name (Medical Doctor) notified. [DATE] 18:11 P.M. Late Entry Nurses Note: The resident's needs cannot be met at this time due to SEE SBAR, after facility attempts to meet the resident needs. The services available at receiving facility can meet the resident's immediate needs at this time. D/C (discharged ) at this time to SEE SBAR. Resident D/C with copies of face sheet, copy of advanced directive, order summary, care plan, D/C summary, bed hold policy, transfer notice. Per family request, resident was to be sent out. Resident #1's Emergency Medical Service's Response/Run sheet dated [DATE] was reviewed and is documented in part, as follows: Call Type: Unconscious/[MEDICAL CONDITION]/Near [MEDICAL CONDITION] Response Mode: Emergent (Immediate Response) Urgency: Immediate Response Times: PSAP(Public safety Answering Point): [DATE] 14:32:14 Unit Dispatched: [DATE] 14:32:39 Enroute: [DATE] 14:33:46 At Scene: [DATE] 14:37:13 At Patient: [DATE] 14:39:44 Depart: [DATE] 14:46:21 Arrive Destination: [DATE] 14:53:45 Provider Impression: Neuro-Unconscious Secondary: Respiratory Impression: Acute Onset Distress Patient Condition: Complaint Type: Chief (Primary) Complaint: unconscious Duration: 10 Minutes Primary Symptoms: Mental Status is unresponsive Other Symptoms: Respiratory arrest Assessment Summary: Skin: warm Mental Status: Unresponsive Interventions: [DATE] 14:44:44 Assist Ventilation-BVM (bag valve mask) Via Mask and Insertion-Oropharyngeal Airway Vitals: [DATE] 14:46:44 Blood Pressure: ,[DATE], Pulse: 50, Respirations: 12 Assisted Ventilations, Oxygen Saturation: 88% on High Concentration 02 (,[DATE] LPM), GCS (Glasgow Coma Scale): 3= (Totally Unresponsive), No eye movement when assessed, No motor response, No verbal/vocal response. [DATE] 14:55:44 Blood Pressure: ,[DATE], Pulse: 56, Respirations: 12 Assisted Ventilations, Oxygen Saturation: 88% on High Concentration 02 (,[DATE] LPM), GCS (Glasgow Coma Scale): 3= (Totally Unresponsive), No eye movement when assessed, No motor response, No verbal/vocal response. [MEDICAL CONDITION]: No Narrative: On location found patient lying supine in bed unconscious and unresponsive. Nursing staff stated patient was eating and began to choke then aspirated. Patient did have a non-rebreather mask on. Nursing staff stated patient did have a history of diabetes, and dementia. When asked staff was unable to give current glucose level of patient. Nursing staff stated patient was eating and began to choke then aspirated. Staff removed food from her mouth then placed on high flow oxygen. Patient had gone unconscious after aspirating. At that time EMS was notified. On location found patient unresponsive with a GCS of 3. Patient had shallow breathing rate of 12 times a minute. Patients skin was warm to touch with a weak pulse. Rapidly placed patient on stretcher. Nurse stated patient had a full DNR (Do Not Resuscitate), crew went to load patient into unit while I went to nursing station to receive paperwork. After several minutes of waiting and conflicting stories, the facility was unable to produce any form of DNR. One staff member stated that in an advanced directive form that the family wanted all life saving measures done. with the confusion and length of time of not being able to provide paperwork I returned to the unit to continue patient care. During transport patients vitals continued to diminish and was unable to maintain her airway. Patient started breathing at a rate of ,[DATE] times a minute with a oxygen saturation of 78%. I placed an oral airway successfully, then used bag valve mask with high flow oxygen to assist with ventilation. I took patient vital signs again and oxygen saturation has improved. Arrived at Name (Hospital) unloaded patient while continuing assisted ventilation. Once in the ED (Emergency Department) staff informed us that the nursing facility had found and sent a current copy of the DNR; at that time all life saving resuscitation was stopped. Placed patient in bed 1. Patient was pronounced dead in the ED by the Physician. Resident #1's Physician History and Physical/Progress Note signed [DATE] was reviewed and is documented in part, as follows: Effective Date: [DATE] 13:38 P.M. Type: Discharge Chief Complaint: Discharge: 82 y.o. (year old) female here for LTC (Long Term Care). Staff reported resident having high grade fever and chills. COVID test was negative. UA (urinalysis) was abnormal. C&S (culture and sensitivity) was sent and [MEDICATION NAME] 2 gm IM was given. Late on she looked better and was eating lunch and got choked on a piece of chicken. Per nurses note finger sweep was done and suction phlegm was done. Family requested to send to ER. Facility received call from ER and she expired in transit. Cause of death: 1. [MEDICAL CONDITION] due to Coronary [MEDICAL CONDITION] exacerbated by Aspiration and UTI (urinary tract infection). she was pronounced at transit to ER. Resident #1's Emergency Department Provider Notes dated [DATE] at 3:15 P.M. were reviewed and are documented in part, as follows: History and Physical : Patient is an [AGE] year-old female with multiple medical problems from the nursing home. According to EMS they were feeding her and they believe that she choked or aspirated. When EMS got there her saturations were low, her respiratory rate gradually declined. The nursing home staff felt that she was a DNR. She was placed into the ambulance, gradually had decrease in respiratory effort, agonal respirations. She arrived here with no pulse, no respiratory effort and the resuscitation was stopped at 2:58 p.m. There was a valid do not resuscitate order that was faxed to us indicating comfort measures only. Review of Systems: Patient unresponsive Physical Exam: Vital signs and nursing note reviewed. Constitutional: General: She is in acute distress. Comments: Unresponsive, agonal respirations that stopped. No pulse. HENT (head, eyes, nose throat): Mouth/Throat: Comments: Some mucus from the mouth. Cardiovascular: Comments: No pulse. Pulmonary: Comments: No respiratory effort. Abdominal: Comments: Abdomen is flat. Skin: Comments: Skin is warm. Neurological: Comments: Unresponsive Clinical Impression: [MEDICAL CONDITION], Aspiration into respiratory tract, initial encounter. Resident #1's Certified Nursing Assistant Documentation Survey Reports for ADL-Eating for the months of [DATE], [DATE], and [DATE] were reviewed and are documented in part, as follows: [DATE] ADL-Eating 0900 A.M. documentation was missing for ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE]. [DATE] ADL-Eating 1:00 P.M. documentation was missing for ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE]. [DATE] ADL-Eating 6:00 P.M. documentation was missing for ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE]. Out of 93 documentation opportunities for ADL-Eating Documentation in [DATE] there were 37 areas of undocumented care provided to Resident #1. [DATE] ADL-Eating 0900 A.M. documentation was missing for ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE]. [DATE] ADL-Eating 1:00 P.M. documentation was missing for ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE]. [DATE] ADL-Eating 6:00 P.M. documentation was missing for ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE]. Out of 93 documentation opportunities for ADL-Eating Documentation in [DATE] there were 43 areas of undocumented care provided to Resident #1. [DATE] ADL-Eating 0900 A.M. documentation was missing for ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] ,[DATE] and ,[DATE]. [DATE] ADL-Eating 1:00 P.M. documentation was missing for ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] ,[DATE] and ,[DATE]. [DATE] ADL-Eating 6:00 P.M. documentation was missing for ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. Out of 89 documentation opportunities for ADL-Eating Documentation in [DATE] there were 52 areas of undocumented care provided to Resident #1. A Telemedicine Visit with Medical Oncology dated [DATE] for Resident #1 was reviewed and is documented in part, as follows: History of Present Illness: Oncology History: [DATE] History of [MEDICAL CONDITION]. [DATE] Surgery Colon resection the right side. Name (Resident #1) is a [AGE] year old female who is called for a telephone follow up of [MEDICAL CONDITION]. She complains of pain. She tells me that she takes a pain pill twice a day. She has lost her teeth and has broken her glasses. She is currently eating soft foods. She states that she has lost some weight. The patient does not have any co-morbidities or personal/family issues that complicate her care. On [DATE] at 12:10 P.M. a phone interview was conducted with Unit Manager (UM) LPN #4 regarding her involvement of Resident #1 on [DATE]. UM LPN #4 stated, Around 9 A.M. she had an acute issue and complained of chills and low grade fever, we assessed her Name (LPN #1) and I. She was put on isolation precautions and a Rapid Covid test was done and was negative. We also had an order to test her for the flu which if negative we were to obtain a urinalysis. We dipped her urine in house and it showed a large amount of leukocytes. Her fever spiked to 102.9 and the doctor ordered [MEDICATION NAME] and she perked up. I left early that day so I wasn't here when she choked but LPN #1 and LPN #3 were. I discussed with Name (LPN #1) the day after about what happened. LPN #1 said she had fed her macaroni and cheese and lima beans when she went to check on her with no issues. She then was called to the room because resident was choking on a piece of chicken LPN #1 cleared the chicken out of her mouth and suctioned her. On [DATE] at 12:17 P.M. a phone interview was conducted with LPN #3 regarding her involvement with Resident #1 on [DATE]. LPN #3 stated, A lady called me 2 weeks ago and said your the one, she questioned me if I knew if it was true that Name (Resident #1) choked on a chicken bone. I told her that there was no bone in the chicken that was in her mouth, that the chicken had been took off the bone. I was on the other hallway that day when I saw and heard Name (LPN #1) running with the suction machine and hollering for help. She said the Name (Resident #1) was not breathing. I ran to Name (Resident #1's) room and she was up in bed and looked like she was struggling to get a breath. Her eyes were half shut, I called her name but she didn't respond. It looked like chicken was in her mouth so I grabbed a glove and did a finger sweep and got the chicken that was inside her mouth and on her tongue. It was about the size of a quarter and a ball of chicken on her tongue. There was a lot of phlegm, we suctioned her and she took a breath. There was no more chicken in her mouth. I never saw her with teeth, Name CNA (Certified Nursing Assistant) #6 was her CNA. Name (Assistant DON) and I ran to start the paperwork, Name (Resident #1) was not coherent. We called 911 and she left on the stretcher. On [DATE] at 12:33 P.M. a phone interview was conducted with LPN #1 regarding her involvement with Resident #1 on [DATE]. LPN #1 stated, I was the charge nurse that day. That morning Name (Resident #1) was cold and shivering. I took her vitals and made the doctor aware. Her temperature went up to 103 and I did a urinalysis and called the doctor. The doctor said to give her [MEDICATION NAME] 1 gram and to check her in an hour and call him back. I went to check on her around 1:30. I fed her some lima beans and some macaroni and cheese and pulled her chicken apart. She feeds herself after her tray is setup and she is on a regular diet. She always eats in her room rarely gets out of bed. After I made her comfortable I left the room and went back to the nurses station to do some charting. The next thing I heard was Name (Housekeeper) yelling, I think she is choking, referring to Name (Resident #1). I ran to Name (Resident #1's) room , sat her up, gave her 2 pats to her back, she coughed. There was a lot of phlegm and chicken. There was a quarter size piece of chicken that wasn't chewed and a lot of drool and phlegm. Name (CNA #6) stayed with her and I ran to get the crash cart for the suction machine. I yelled for Name (LPN #3) to come help and the Assistant Director of Nursing also came to the room. She (Resident #1) was deteriorating, I suctioned a lot of phlegm out of her mouth and Name (LPN #3) did a quick mouth sweep and got a small piece of chicken out. Name (LPN #3) left the room to call the family. Name (Resident #1's ) oxygen saturations dropped and her eyes were rolling back in her head. I put oxygen on her via a nasal cannula at 4 lpm then switched to a non-rebreather mask at 8 lpm. EMS arrived and told them what was going on and that family wanted her to go to the ER. The hospital called and said she had expired. On [DATE] at 12:55 P.M. a phone interview was conducted with CNA #6 regarding Resident #1 on [DATE] and the assistance provided to the resident during meals. CNA #6 stated, I'm the normal CNA for the unit. For Name (Resident #1) we just set her tray up, open things and she feeds herself. On the day she choked I heard Name (Housekeeper) yelling Name (Resident #1) is choking. So I hollered for Name (LPN #1) to come help. Name (LPN #1) set her up and hit her on her back to get food and phlegm up. Name (LPN #1) went to get the crash cart for the suction machine. I stayed in the corner out of the way. On [DATE] at 1:22 P.M. a phone interview was conducted with the Housekeeper regarding her involvement with Resident #1 on [DATE]. The Housekeeper stated, I go to see her (Resident #1) everyday. I went to her room that day to put her clothes away and saw she was on oxygen. I spoke to her, she didn't speak at all, I figured she was not feeling good She usually says Hey Girl. Her lunch tray was in front of her, she had been feeding herself. I noticed that she had spilt her juice and tea all over her tray, fluids were spilled in her food. I said You don't feel good and she just kept looking at me. I left for a good 5 to 7 minutes to take the linen cart back and get my cleaning cart. As I was coming back down the hall with my cart I heard someone going UGH, UGH! real loud near Name (Resident #1's) room. I thought it was the roommate because she has a deep voice. I walked in the room and asked the roommate if she was ok and she said she was. Then I saw Name (Resident #1) was slumped over to the side, she was not sitting up like usual. Her eyes were weak and she was gagging. I looked at Name (Resident #1) and saw chicken coming back out of her mouth. She was choking bad, scared me so bad. I ran up to the nurses desk and said Name (Resident #1) choking. The nurse came running down. I knew something was not right because her tray was a mess and I saw the chicken coming out of her mouth. I'm not allowed to touch her. There was noting I could do but hurry and get help. Surveyor asked the Housekeeper if they were any other staff in the room assisting Resident #1 with her lunch the two times she entered the room. The Housekeeper stated, No, there were no staff in the room. On [DATE] at 7:57 A.M. a phone interview was conducted with the facility Medical Director who was also Resident #1's Attending Physician. The Medical Director was made aware of Resident #1's assessed need of requiring supervision with one person physical support for eating and based on that resident assessment what would he expect for his resident. The Medical Director stated, Someone should have been there with her, I was not aware she was alone. The Medical Director was also asked if he was aware that on [DATE] Resident #1 was found choking on chicken prior to being sent out via 911. The Medical Director stated, Yes, they did tell me she was choking. She has had a decline/getting worse over the last 6 months. Let me tell you COVID is an issue, the staff are exhausted and they are doing the best they can. On [DATE] the Medical Director asked to speak with this surveyor again so at 8:06 A.M. another phone interview with the Medical Director was conducted. The Medical Director stated, I just spoke with Name (Assistant Director of Nursing) and she said Name (Resident #1) had no history of choking and that the episode on [DATE] was a one-time episode. On [DATE] at 12:28 P.M. a phone exit briefing was conducted with the Administrator and the above findings were shared. The Administrator was asked what was the purpose of the MDS. The Administrator stated, It is what we are supposed to go by for the resident care. It tells us what we need to assist or not assist the resident with. The Administrator was asked for any facility polices for staff assisting residents with meals based on MDS coding. The Administrator emailed this surveyor with the following statement which is documented in part, as follows: There was no policy on assistance with feeding or supervision. We would performing the task according to how the resident is coded on the MDS according to the RAI (Resident Assessment Instrument) manual. No further information was received and the survey was concluded. Complaint deficiency.

Based on observations, complaint investigation, record reviews, facility documentation, and staff interviews, the facility staff failed to maintain a safe environment to prevent access to contaminated drinking water for 16 of 23 residents with [DIAGNOSES REDACTED].#2, #3, #6, #8, #12, #13, #14, #15 and Residents #17 through #23) in the survey sample of 23 residents. The facility also failed to post signs in all entries and common areas to alert the public and residents that the facility was experiencing contaminated drinking water resulting in Immediate Jeopardy. The findings Included: The facility staff failed to ensure Environmental Safety after experiencing contaminated water with the Coliform Bacteria in their drinking water since July 16, 2017. The facility did not have posting of signs in any entries and common areas to notify the public as well as residents to not consume or use water from any tap source. The facility also failed to prevent Residents with dementia access to water in rooms which they could potentially consume causing gastrointestinal symptoms resulting in Immediate Jeopardy. Immediate Jeopardy was identified at 3:36 P.M. on 8/9/17. The facility experienced contaminated water following a water pump failure on July 16, 2017. The administrator provided the following information Coliform in Your Water from the University of Georgia College of Agricultural and Environmental Sciences Cooperative Extension: The water was found to contain Coliform Bacteria. Bacteria are common organisms in nature. They are very small in size. A pinhead can accommodate millions of bacteria. Living in numerous environments, bacteria perform both beneficial and harmful activities. Most bacteria are harmless to human health; however, some are pathogenic, capable of causing disease. Coliform are a large group of several types of bacteria from the same family. Most are abundant in soils, surface water and vegetation. Some Coliform bacteria originate from human or animal fecal sources. Most Coliform bacteria are harmless to humans, but some can cause illnesses and a few can lead to serious waterborne diseases. Bacterial contamination of drinking water does not change the appearance, smell or taste of water. Testing by a laboratory is the only way to know if water contains Coliform bacteria. This facility tested positive for Total Coliform-which is one of three Coliform pathogens. Test results showing the presence of total Coliform indicate that the water is contaminated. Contamination sources may include dirty surface water, leaky sewer/septic system, animal waste, etc. These contaminants enter the water supply through a pathway (for example, cracks/holes on the well casing or unsealed/ungrouted spaces between the bore hole and well casing). Water containing any total Coliform or E.Coli should not be used for drinking or food preparation unless you boil it for a minimum of five minutes or the water is disinfected by other means. This also includes water used for making ice, coffee, brushing teeth, washing fruits and vegetables eaten raw. A facility Time Line of Events dated (8/10/17) indicated: On July 16, 2017 at midnight the generator powered on due to a facility power surge. Generator ran all night. At 4:30 A.M. staff noticed decrease in water pressure. At 6:00 A.M. electrician determined bad water pump. No water available to the facility. Cause of bed pump was loss of electrical phase where pump kept trying to run on 2 phases. Fire watch implemented. At 7:45 A.M. Outside vendor onsite to evaluate and begin repair. At 1:00 P.M. water pump replaced. 1st round of disinfection occurs (Shock disinfection- 2 gallons of Clorox 51/4) Fire watch discontinued as water available for fire suppression. Phone conference with VDH (Virginia Department of Health) reviewed situation and what it would take to lift well water, in collaboration with local health department precautions implemented (boil water precaution, hand sanitizer, potable machines in kitchens, disposable dishware, bottle water, triple filtered with UV (ultraviolet) water system implemented for kitchen, baths in bag ordered, notified residents and families). July 17th On site visit by local health department to inspect kitchen and ensure everything we are doing is correct. July 17 - July 23- July 19 another round of disinfection occurs (Shock disinfection with 4 gallons of Clorox 6). July 20- a second outside vendor, completes a round of disinfection (Shock disinfection with 2 gallons with Clorox 8 1/4). July 22- phone conference with VDH - review of results, redo shock. July 23- another round of disinfection, performed (Shock disinfection with 2 gallons with Clorox 8 1/4 %, disinfection at 8-10 hours with flush). July 24 - phone conference with VDH-in collaboration with the local health department: Alternated sample collection to eliminate possible contamination-bleached faucet and backflow. July 25- On site with local health department, traced chlorine residuals. wet down casings at 20 minute intervals. July 28- Vendor #1 supply 1200 gallons of treated water for super chlorination (15 gallons of chlorine -5 1/4 concentration of well to get deeper into well. Instilled over 2 hours. flushed over 2 hours. July 29- Phone conference with local health department - confirmed planned of 24 detention time. July 30- 24 hour disinfection Shock disinfection (24 detention time) with 5 gallons with 8 1/4 chlorine concentration. July 30 - Turned well off at 6:00 A.M., 5 gallons of 8 1/4 concentration chlorine, flushed the system at 0700 on 7/31. 0830 all faucets in facility opened to flush chlorine from system. July 31-August 6th - July 31 - Stopped new admissions (accepted returns) - Phone conference with local health department- review test results August 1st- and 2nd - Phone conference with local health department - reviewed test results Week of August 7th August 7th - cleaned and disinfected the water tank, power washed tank and cleaned debris. 8 1/4 chlorine- 3 gallons flushed. After system brought back online chlorine tablets placed. August 7th -15 3 inch chlorine tablets put into the water tank. Efforts to mitigate: Use of bottled water, both 5 gallon jugs and 16 oz bottles. Utilization of parent company emergency management water purification system. Three 2 gallon per minute units were installed. One installed for ice machine and coffee maker in the kitchen. One for the large washing sink in the kitchen, One for a shower. This system is manufactured and certified to USEPA NSF P248 and P231 standards. Use of bagged ice. Use of Bath in a Bag. This product utilizes wash cloths with a no-rinse liquid cleanser. A warmer was transferred from parent company to warm the bags prior to use. Use of disposable and paper products for plates, cups and utensils. Facility's parent company nutrition services full involvement to ensure appropriate meal plans and meeting resident nutritional needs. Other Important Information: We have been in continual contact with the VDH Office of Drinking Water. Contact person has provided guidance throughout the process and is unsure why we keep getting positive results. Contact person visited site on July 25th. We have been in contact with Consulting firm for short and long term solutions which are under review by management. Half way through testing process Laboratory vendor began collecting samples to make sure samples were not accidentally being contaminated. We have utilized three outside vendors for lab testing. Continual updates with facility, division, and upper management leadership. We have attempted no less than 6 disinfection/chlorination attempts. Monthly Testing Requirement: Monthly samples being collected per 12 VAC 5-590-370. Sampling Frequency State Administrative Law. Last updated: 8/10/17. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set ((MDS) dated [DATE] assessed this resident in the area of Hearing, Speech and Vision as being able to understand sometimes to simple direct communication. In the area of Cognitive Pattern this resident was assessed as having a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 indicating severe cognitive impairment. Resident #1 was assessed in the area of Activities of Daily Living (ADL) in the area of Mobility as requiring Total Dependence on staff. No mobility devices were coded. A revised Care Plan dated 10/18/16 indicated Problem: Resident is at risk for compromised quality of life secondary to: Impaired Cognition. Intervention: Keep resident's environment free of potential hazardous substances. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] assessed this resident in the area of Hearing, Speech and Vision as misses some part/intent of message. This resident had a BIMS score of 7 indicating severe cognitive impairment. Resident #2 was assessed in the area of ADL'S Mobility as requiring Extensive assistance of staff. No mobility devices were coded. A revised Care Plan dated 9/23/16 indicated Problem: Resident is at risk for compromised quality of life secondary to: Impaired Cognition. Intervention: Keep resident's environment free of potential hazardous substances. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] assessed this resident in the area of Hearing, Speech and Vision as able to express ideas and wants. This resident had a BIMS score of 3 indicating severe cognitive impairment. Resident #3 was assessed in the area of ADL'S Mobility as requiring Limited assistance of staff. Resident uses wheelchair and walker for mobility. A revised Care Plan dated 9/2/16 indicated: Problem: Resident is at risk for compromised quality of life secondary to: Impaired Cognition. Intervention: keep resident's environment free of potential hazardous substances. 4. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] assessed this resident in the area of Hearing, Speech and Vision as able to express ideas and wants. This resident had a BIMS score of 9 indicating moderate cognitive impairment. Resident #6 was assessed in the area of ADL'S Mobility as requiring Supervision. Resident uses walker for mobility. A revised Care Plan dated 10/20/16 indicated: Problem: Resident is at risk for compromised quality of life secondary to: Impaired Cognition. Intervention: keep resident's environment free of potential hazardous substances. 5. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] assessed this resident in the area of Hearing, Speech and Vision as having impaired vision and able to express ideas and wants. This resident had a BIMS score of 9 indicating moderate cognitive impairment. Resident #8 was assessed in the area of ADL'S Mobility as requiring Extensive assistance of staff. Resident uses walker for mobility. A revised Care Plan dated 12/22/16 indicated: Problem: Resident is at risk for compromised quality of life secondary to: Impaired Cognition. Intervention: keep resident's environment free of potential hazardous substances. 6. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Initial MDS dated [DATE] assessed this resident in the area of Hearing, Speech and Vision as able to express ideas and wants. This resident had a BIMS score of 4 indicating severe cognitive impairment. Resident #12 was assessed in the area of ADL'S Mobility as requiring Limited assistance of staff. Resident uses wheelchair for mobility. A Care Plan dated 6/13/17 indicated: Problem: Resident is at risk for compromised quality of life secondary to: Impaired Cognition. Intervention: keep resident's environment free of potential hazardous substances. 7. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] assessed this resident in the area of Hearing, Speech and Vision as able to express ideas and wants. This resident had a BIMS score of 5 indicating severe cognitive impairment. Resident #13 was assessed in the area of ADL'S Mobility as requiring Extensive assistance of staff. Resident uses wheelchair for mobility. A revised Care Plan dated 8/16/16 indicated: Problem: Resident is at risk for compromised quality of life secondary to: Impaired Cognition. Intervention: keep resident's environment free of potential hazardous substances. 8. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].>Parkinson's Disease and Dementia. A Quarterly MDS dated [DATE] assessed this resident in the area of Hearing, Speech and Vision as misses some part/intent of message. This resident had a BIMS score of 5 indicating severe cognitive impairment. Resident #14 was assessed in the area of ADL'S Mobility as requiring Supervision of staff. Resident uses a cane for mobility. A revised Care Plan dated 5/3/17 indicated: Problem: Resident is at risk for compromised quality of life secondary to: Impaired Cognition. Intervention: keep resident's environment free of potential hazardous substances. 9. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Significant Change MDS dated [DATE] assessed this resident in the area of Hearing, Speech and Vision as misses some part/intent of message. This resident had a BIMS score of 4 indicating severe cognitive impairment. Resident #15 was assessed in the area of ADL'S Mobility as requiring Supervision of staff. Resident ambulates Independently. A revised Care Plan dated 12/21/16 indicated: Problem: Resident is at risk for compromised quality of life secondary to: Impaired Cognition. Intervention: keep resident's environment free of potential hazardous substances. 10. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] assessed this resident in the area of Hearing, Speech and Vision as missing some part/intent of message. This resident had a BIMS score of 3 indicating severe cognitive impairment. Resident #17 was assessed in the area of ADL'S Mobility as requiring Total Dependence of staff. No mobility device were coded. A revised Care Plan dated 10/13/16 indicated: Problem: Resident is at risk for compromised quality of life secondary to: Impaired Cognition. Intervention: keep resident's environment free of potential hazardous substances. 11. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Significant Change MDS dated [DATE] assessed this resident in the areas of Hearing, Speech and Vision as able to express, ideas and wants. This resident had a BIMS score of 10 indicating moderate cognitive impairment. Resident #18 was assessed in the area of ADL'S Mobility as requiring Extensive assistance of staff. Resident uses a wheelchair for mobility. A revised Care Plan dated 10/5/16 indicated: Problem: Resident is at risk for compromised quality of life secondary to: Impaired Cognition. Intervention: keep resident's environment free of potential hazardous substances. 12. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This resident had a BIMS score of 12 indicating moderate cognitive impairment. Resident #19 was assessed in the area of ADL'S Mobility as requiring Extensive assistance of staff. Resident uses a wheelchair for mobility. A revised Care Plan dated 10/13/16 indicated: Problem: Resident is at risk for compromised quality of life secondary to: Impaired Cognition. Intervention: keep resident's environment free of potential hazardous substances. 13. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This resident had a BIMS score of 9 indicating moderate cognitive impairment. Resident #20 was assessed in the area of ADL'S Mobility as requiring Extensive assistance of staff. Resident uses a wheelchair for mobility. A revised Care Plan dated 8/19/16 indicated: Problem: Resident is at risk for compromised quality of life secondary to: Impaired Cognition. Intervention: keep resident's environment free of potential hazardous substances. 14. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This resident had a BIMS score of 5 indicating severe cognitive impairment. Resident #21 was assessed in the area of ADL'S Mobility as requiring Extensive assistance of staff. Resident uses a wheelchair for mobility. A revised Care Plan dated 8/10/16 indicated: Problem: Resident is at risk for compromised quality of life secondary to: Impaired Cognition. Intervention: keep resident's environment free of potential hazardous substances. 15. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This resident had a BIMS score of 0 indicating severe cognitive impairment. A revised Care Plan dated 10/7/16 indicated: Problem: Resident is at risk for compromised quality of life secondary to: Impaired Cognition. Intervention: keep resident's environment free of potential hazardous substances. 16. Resident #23 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. This resident had a BIMS score of 0 indicating severe cognitive impairment. Resident 23 was assessed in the area of ADL'S Mobility as requiring Extensive assistance of staff. No device for mobility was coded. A revised Care Plan dated 8/10/16 indicated: Problem: Resident is at risk for compromised quality of life secondary to: Impaired Cognition. Intervention: keep resident's environment free of potential hazardous substances. Residents were observed in a variety of environments without posted of signs that the facility was experiencing contaminated water and not to use for consumption. There were no signs observed on August 9, 2017 indicating the water was not to be used for consumption in the following locations: Front Lobby Side Entrance Boardroom bath room Beauty shop Men's bathroom (front lobby) Women's Bathroom (front lobby) A Wing Shower (Both) A Wing Storage Room A Wing Shower Room A Wing Biohazard Room B Wing Shower (Both) C Wing Shower Room (Both) C Wing Biohazard Room Sewing Room on B-Unit Bathroom by Activity Room Sink In Main Dining Room Residents as well as family and members of the public were observed on 8/9/17 using the Men's and Women's bathroom located in the front lobby. Lab Collections: Identifiers - Vendor #1,2, 3. Location: Tap 1=Well, Tap 2 = Outside Filtration System, Tap 3 = Inside Building Vendor Date Time Date of Results Location Results Test time Total Coliform's E.Coli #1 7/16/17- 3:52 P.M. 7/17/17 Tap 1 Neg. 24 hr. absent absent #1 7/17/17- 3:49 P.M. 7/18/17 Tap 1 Post. 24 hr. present absent #1 7/18/17 1:30 P.M. 7/19/17 Tap 1 Post. 24 hr. present absent #1 7/18/17 1:30 P.M. 7/20/17 Tap 1 Post. 24 hr. present absent #1 7/21/17 8:20 A.M. 7/22/17 Tap 2 Post. 24 hr. present absent #1 7/22/17 8:33 A.M. 7/23/17 Tap 2 Post. 24 hr. present absent #1 7/23/17 9:05 A.M. 7/24/17 Tap 2 Post. 24 hr. present absent #1 7/24/17 11:00 A.M. 7/25/17 Tap 3 Post. 24 hr. present absent #1 7/26/17 11:30 P.M. 7/27/17 Tap 3 Post. 24 hr. present absent #1 7/27/17 1:42 P.M. 7/28/17 Tap 2 Neg. 24 hr. absent absent #1 7/27/17 1:44 P.M. 7/28/17 Tap 1 Post. 24 hr. present absent #1 7/27/17 1:45 P.M. 7/28/17 Tap 1 (rt) Neg. 24 hr. absent absent #1 7/28/17 2:35 P.M. 7/29/17 Tap 1 Post. 24 hr. present absent #1 7/31/17 8:50 A.M. 8/01/17 Tap 1 Post. 24 hr. present absent #1 7/31/17 7:15 A.M. 8/01/17 Vent Neg. 24 hr. absent absent #1 7/31/17 9:00 A.M. 8/01/17 Tap 3 Neg. 24 hr. absent absent #2 7/31/17 2:05 A.M. 8/02/17 Tap 1 Neg. 48 hr. absent absent #1 8/01/17 9:15 A.M. 8/02/17 Tap 3 Neg. 24 hr. present absent #2 8/01/17 2:10 P.M. 8/03/17 Tap 3 Post 48 hr. absent absent #2 8/01/17 2:00 P.M. 8/03/17 Tap 2 Post 48 hr. present absent #2 8/02/17 3:25 P.M. 8/04/17 Tap 1 Post 48 hr. present absent #3 8/03/17 11:15 A.M. 8/5/17 Tap 2 Post 48 hr. present absent #3 8/04/17 12:00 P.M. 8/7/17 Tap 2 Post 48 hr. present absent #3 8/08/17 12:00 P.M. Pending Tap 2 Post 48 hr. #3 8/09/17 1:00 P.M. Pending Tap 1 pending 48 hr. #3 8/09/17 1:00 P.M. Pending Tap 2 pending 48 hr. #3 8/09/17 1:00 P.M. Pending Tap 3 pending 48 hr. #1 8/09/17 2:00 P.M. Pending Tap 1 pending 24 hr. #1 8/09/17 2:00 P.M. Pending Tap 2 pending 24 hr. #1 8/09/17 2:00 P.M. Pending Tap 3 pending 24 hr. An Emergency Management Policy last revised 2/20/17 indicated: It is the purpose of this plan to maintain reliable communications capabilities for communicating response efforts to staff, patients/residents/participants and their families, and external organizations as appropriate. Policy - Water- water for consumption and essential care activities is provided by water service authorities or on-site wells approved for such use. The Entity maintains a supply of potable water. In anticipation or in the event of a potable water loss facilities will coordinate with their water supply vendor to increase potable water supply. This will be coordinated through the facility command center. On-site storage will be increased as available. The Entity maintains a portable First Water system that can be deployed to any facility. The system has the capability of producing in excess of 35,000 gallons of potable drinking water a day. In addition, the Entity maintain a cache of potable drinking water in 5 gallon jugs and water bottles as well as bladders that can be filled. Non-potable water sources may be utilized for flushing toilets and other acceptable needs as determined by the facility department working in conjunction with the facility command center. A letter dated August 10, 2017 from the food and water outside vendor indicated the following: In the event an emergency or natural disaster, our healthcare customers are our top priority. The vendor will make available to the healthcare customers (to the extent possible): Emergency Off- Day Delivers Cooking Supplies-Steam Table trays, Sterno, etc. Paper Products- Tissues, Towels, Wipes, etc. Food Supplies-Cereal, Non-Fat Dry Milk, Instant Foods, Canned Juices, Bottled Water, Coffee, Portioned Control Items, etc. Be it known that the above mentioned customer gets a scheduled delivery from said Vendor every Wednesday and Friday. In addition they have now been receiving an extra day delivery on Mondays to meet their EMERGENCY needs. These orders have consisted of several hundred cases of water, paper trays, disposables, cutlery, food, juices, coffee, supplements, cereal and other housekeeping needs. Electronic signature by Account Executive and Manager. During an interview on August 9, 2017 at 1:30 P.M. with the Administrator, she stated, We have informed all of our residents and family's concerning our water situation. We notified the families by phone and face to face. We had a sign made for the July 30, 2017 water cut off that was posted throughout the building. All residents were notified as well. We notified the family's and residents that the water would be turned off on Sunday July 30th for 24 hours as we flushed our water pump system to get it back to full function. The family's as well as the residents were notified that they will continue to receive bottled water, have hot meals and use the bathroom. When asked if the signs remained up to notify the public of unsafe water, the Administrator stated, No. There was no evidence of any gastrointestinal symptoms during this time. On 8/9/17 at 3:36 P.M. Immediate Jeopardy level 4 widespread was called at a scope and severity of Level 4 widespread- substandard. The following plan of correction was submitted by administration: 1. Immediate cutoff of all sinks in a resident accessible area. Posting of signage at all entries and common areas to not consume or use water from any tap, etc. All directed by Administrator to be completed on 8/9/17. 2. All residents are at risk. All residents will be informed of risk of utilizing facility tap water and cutting off of sinks and all water access by leadership staff. 3. Immediate education to all staff and residents not to consume or utilize any water from any tap in the facility by nursing leadership staff on 8/9/17. Notification of Medical Director by Administrator on 8/9/17. 4. Administrator/Designee will round daily to check all rooms and common areas for continued non-availability of water daily for 7 days and then random checks in 4 resident rooms and each common area daily until water is restored. 5. All initiated by 8/9/17. Posted signs indicated: Visitors, Residents and Staff STOP Please do not drink or use any tap water in this facility for yourself or provide to Residents. Only Use bottled water Please see nurse for additional questions or concerns Thank You, Administrator Signs were observed in the following locations: Boardroom, Beauty Shop, Men's Bathroom (Front Lobby) Side Entrance Women's bathroom (Front Lobby), A- Wing Shower (Both), A- Wing Storage Room, A-Wing Biohazard, B-Wing Shower (Both), B-Wing Biohazard, C-Wing Shower Room, C- Wing Biohazard Room, Sewing Room of B- Unit, Bathroom by Activity Room, and Activity Room Sink. The plan of correction was received by survey team, reviewed and accepted at 4:05 P.M. on 8/9/17. Complaint Deficiency

Based on resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to provide prompt pain management for 1 of 22 residents (Resident # 19) causing a high level of distress. Specifically, the facility staff failed to provide prompt pain management from approximately 8:00 p.m. through approximately 12:00 p.m. for Resident #19 admitted to the facility with an assessed 9 out of 10 pain level post total knee replacement surgery. Resident #19 reported a high level of pain to the facility staff and requested assistance multiple times and received no relief from pain. As a result, Resident #19 called 911 (emergency services) to assist with pain management. Resident #19 was under a high level of distress that she felt she had to leave the facility to receive pain management services. The findings included: Resident #19 was admitted to the facility on [DATE]. Several documents reported different times (6:00 p.m. and 8:00 p.m.) of Resident #19's arrival to the facility. Resident #19 was reported to have left the facility at approximately 12:00 a.m. via non-emergency services. [DIAGNOSES REDACTED]. Resident #19 did not have a completed Minimum Data Set (MDS), an assessment tool. The facility Admission Nursing assessment dated [DATE] with a time of 2009 (8:09 p.m.) documented Resident #19 to be alert and oriented x 3 (oriented to person, place, and time). According to the face sheet Resident #19 was admitted on [DATE] at 6:00 p.m. and was her own responsible party (able to make her own decisions). No observations were made regarding Resident #19 as she was no longer at the facility during the survey dates from 11/29/16 through 12/1/16. On 12/30/16, Resident #19's clinical record was reviewed. According to the Hospital Discharge Summary Resident #19 last had [MEDICATION NAME] 10-325 MG on 3/14/16 at 14:25 (2:25 p.m.). Also, the Hospital Discharge Summary documented Resident #19's discharge date on 3/14/16 at 3:36 p.m. Transportation services documentation detailed that Resident #19 departed from a Maryland hospital at 1745 (5:45 p.m.) and arrived at the facility at 2022 (8:22 p.m.) and confirmed that several stops were made to include a 30 minute wait for a [MEDICAL TREATMENT] patient. The facility Face Sheet documented Resident #19 was admitted on [DATE] at 6:00 p.m. The facility Admission Nursing Assessment was dated 3/14/16 with a time of 2009 (8:09 p.m.). On 3/14/16, Resident #19's physician's orders [REDACTED]. Also on this faxed copy of orders were standing orders that included but not limited to: [MEDICATION NAME] 650 MG by mouth every 4 hours as needed for mild pain and [MEDICATION NAME] 650 MG suppository by rectum every 4 hours as needed for mild pain. A signed physician's script from the hospital for [MEDICATION NAME] 10-325 MG started on 3/14/16 (with no time) was presented by the facility. This order documented .5-1 tablet by mouth every 3-6 hours as needed for pain. On 3/14/16 two electronically signed orders from a facility on-call NP (Nurse Practitioner) were made. The first order was electronically signed on 3/14/16 at 10:36 p.m. documented under Medications to change medication from [MEDICATION NAME]-[MEDICATION NAME] 10-325 MG Tablets, 0.5-1 tablet by mouth as needed for pain, take every 3-6 hours as needed. Indications: Pain to *[MEDICATION NAME] 5-325 MG tablets, 2 tablets by mouth every 4 hours as needed for pain. Indications: pain. The second order was electronically signed on 3/14/16 at 10:38 p.m. by the facility on-call NP. This order was a refill for [MEDICATION NAME] 5-325 MG tablets and was made to the local pharmacy and read, [MEDICATION NAME] 5-325 MG 2 tablets by mouth every 4 hours as needed for pain. According to the medication log dated 3/10/16 presented by the facility staff, three (3) [MEDICATION NAME]/APAP 5-325 MG tablets were available in the automated medication dispensing system in the facility on 3/14/16. There were no MARs (Medical Administration Record) for Resident #19 in the clinical record indicating no medication was given to Resident #19. The TAR (Treatment Administration Record) for Resident #19 was complete with no treatments performed. There was only one nursing note. The nursing note dated 3/15/16 at 0306 (3:06 a.m.) read Resident #19 arrived at 2009 (8:09 p.m.) .complained of pain 9 out of 10, right knee related to recent knee replacement .resident was under the impression that her pain medication would be here upon arrival .the pharmacy did not enter in any medications until after 0100 (1:00 a.m.) .the NP called in [MEDICATION NAME] 5/325 mg to the pharmacy but the pharmacy did not have the medications under the resident's profile .the pharmacy was called and told me to pull from the stat box but it (the medications) isn't in the stat box (facility does not use a stat box) .resident stated she wanted to go to the hospital for pain management .attempted to explain the process but she insisted on going to the hospital .she told me to call 911 because she could not take PO (by mouth) medications because it would take 2 hours to work .the NP was notified and she told me to send her (Resident #19) out because we (the facility) were unable to take care of her pain .ambulance called and came but advised her to use non-emergency transport .transport carrier took resident to the hospital. The facility Pain Assessment form in Resident #19's clinical record was blank. The Interim Plan of Care presented by the facility staff was a standard form with no specific details or dates regarding Resident #19 but the resident's name was present. On the Interim Plan of Care under the section titled, Potential for Pain is was documented as a goal, Resident will have pain relieved and it was documented as an intervention to: Administer pain medication as prescribed by physician with an approach: Assist resident with positioning for comfort, ask resident frequently if pain medication or other treatment is being effective; if continued pain is present to notify the physician. Transportation services from the facility to the hospital per resident's request after not receiving her pain medication was presented by the facility staff. This documented that Resident #19 was transported on 3/15/16. The transportation arrived at the facility at 0106 (1:06 a.m.) and arrived at the hospital at 0148 (1:48 a.m.). On the transportation documentation under the section titled, Additional Comments it read: .Took vitals which were all a little high due to the pain she is in, she had right knee replacement 1 week ago and the onset of this pain was during transportation earlier this evening. Also, on this document Resident's pain was scored at a 10 out of 10 on the pain scale. Vital signs were taken by the transport staff at 0117 (1:17 a.m.) were documented as followed: blood pressure 171 over 88, pulse 101, respirations 24, oxygen sat 98 percent and GCS (Glasgow Coma Scale-to assess impaired consciousness, brain damage) 14 out of 15 indicated mild impairment (score of 13-15). The Hospital emergency room Registration documented under the section titled, Problem in own words: Right knee pain. The Hospital Patient Care Report documented under the section titled, History of Present Illness: Found pt (patient) lying in bed complaining of severe rt (right) knee pain. She had knee replacement 1 week ago at (hospital in Maryland) transferred from (hospital to facility) about 5-6 hours ago. Onset of pain during transport. (Facility had no pain meds(medications). The Hospital Triage Notes read, Right knee pain, Pt (patient-Resident #19) left the hospital (in Maryland) at 1700 (5:00 p.m.) and got to the facility around 1930 (7:30 p.m.). Patient requested pain medication upon arrival to nursing home due to transport and was told that they did not have any pain medication available and that pt (patient) should have gotten discharge medications from the hospital (in Maryland). Pt (patient was told she would have to wait until later in the evening or early morning for pain medications. Also documented was Pain level 10 hurts worst, using faces pain scoring. Under the section titled Pain on 3/15/16 at 09:52 a note documented that Resident #19 has aching, dull pain to the right knee, on a scale of 1-10 patient rates pain as 2, pain exacerbated by nothing and pain relieved by opiate medications. On 11/30/16 at approximately 10:13 am, Resident #19 was interviewed via phone. Resident #19 stated that she was poorly transported from the Maryland hospital to the facility in Virginia and was in pain for the duration of the ride which was prolonged by a stop for another resident. Resident #19 believes she arrived at the facility on 3/14/16 around 6:00 p.m. and was in pain at a 10 (the highest rating) plus. Resident #19 stated, I asked the nurse for pain medication and she said, 'we don't have your medication.' Following this Resident #19 explained, They took me to the room and evaluated me and the nurse left and the aide (can't remember her name) put me on the bed pan and after I asked her, please ask the nurse to come in.' The resident waited for an hour because her call bell had fallen on the floor. The same aide came in and said 'The nurse was busy and when she is finished will come in. The nurse came in 20 minutes later. This is when Resident #19 asked to call 911 because she was in pain and could not wait another 45 minutes. Resident #19 remembers it took 25 minutes to drive to the hospital and stated, When I got to the hospital-I needed something to get out of pain; I was shaking and crying tears. The hospital gave her medication and she was able to sleep. Resident #19 added, I was in excruciating pain for at least two hours or more and you should know, I'm not a cry baby. Finally she stated, The nursing home (staff) said I can't get any medications until following day by .I can't remember the time. When asked if the staff offered anything to relieve the pain, Resident #19 stated, Absolutely nothing! Positioning? No. Tylenol? Nothing. On 11/30/16 at approximately 11:00 a.m. the DON (Director of Nursing) explained it took Resident #19 an hour plus to arrive from the Maryland hospital and she had no hard script so the NP (Nurse Practitioner) called in the script for [MEDICATION NAME]. The facility does not have a stat box as the automated medication dispensing machine is used for storing medications. The RN (registered nurse) that admitted Resident #19 was still currently working the night shift at the facility but the NP was not available. Finally the DON stated, This was not good .this situation (Resident #19 in pain without medication) was not good and I was not called but found out about it the next morning. On 11/30/16 at approximately 5:00 p.m., the DON presented a timeline of the events surrounding Resident #19's admission and time at the facility on 3/14/16. The contents of this timeline included but not limited to: On 3/14/16 1705 (5:05 p.m.) Facility faxed medication list to Pharmacy 1700 (5:00 p.m.) is the cut off time for the next run time for medications 1851 (6:51 p.m.) Received report from Maryland Hospital (Patient already discharged from the hospital when the report was called, discharged via wheelchair van, transportation arranged by Maryland Hospital, multiple stops, and the last pain medication was at 14:25 (2:25 p.m.) 2009 (8:09 p.m.) Patient arrives, complaining of knee pain Admission assessment completed- took approximately 1 hour 2020 (8:20 p.m.) Script for [MEDICATION NAME]/APAP ([MEDICATION NAME]) 10/325 MG faxed to Pharmacy 2241 (10:41 p.m.) Nurse accessed automated dispensing system, no medication pulled 2243 (10:43 p.m.) Nurse called NP regarding need for new pain medication order- [MEDICATION NAME]/APAP 10/325 MG not available in facility 2256 (10:56 p.m.) Nurse called Pharmacy and received authorization to pull [MEDICATION NAME] 5/325 MG tablets 2301 (11:01 p.m.) [MEDICATION NAME]/APAP 5/325 MG entered by Pharmacy 2311 (11:11 p.m.) Nurse accessed automated dispensing system, no medication pulled 2353 (11:53 p.m.) Nurse accessed automated dispensing system, no medication pulled 0000 (12:00 a.m.) 3/15/16 Patient transferred to hospital 0011 (12:11 a.m.) RN called Pharmacy to ensure [MEDICATION NAME] out for delivery 0146 (1:46 a.m.) [MEDICATION NAME]/APAP 5/325 MG arrived at the facility 0417 (4:17 a.m.) Other admission medications arrived at facility On 11/30/16 at 5:00 p.m. the DON, Administrator, and Administrative staff #5 were interviewed regarding the timeline. Administrative staff #5 and Administrator stated, We had no hard script and should not accept another resident without hard scripts. Administrative staff #5 added that education was conducted after the incident to include pain assessment, non-verbal, skills fair, and how to get medication. The DON added a nursing staff supervisor was hired for the night shift to improve the admission process and educated staff (the RN specifically involved and all nursing staff) to utilize the resource of the on-call nursing management. The DON will assist with transitions and quarterly meetings will address transitions. Communication increased with the Maryland Hospital, with the Pharmacy, and with the physicians to improve attempts to have scripts. It was confirmed at this interview that Resident #19 had suffered at least 4 hours of pain while in the facility from 8:00 p.m. until 12:00 a.m. The DON stated, She should not have had to go through the pain and suffering. The administrative staff agreed that the expectation is timely delivery of pain management. On 11/30/16 at 8:30 p.m. RN #21, the admitting nurse for Resident #19 was interviewed. RN #21 was asked how did Resident #19 present and answered, She was already in pain when she arrived around 8:00 p.m. RN #21 explained that she did the admission assessment and Resident #19 rated her pain a 9 out 10 on the scale from 1 to 10, 10 being the worst. RN #21 continued to explain that an aide assisted Resident #19 and that a hard copy for [MEDICATION NAME] came with Resident #19 and was faxed to the Pharmacy. RN #21 stated, There was nothing in the (name of automated medication dispensing system) .no medications can be pulled until loaded in the resident profile, the pharmacy tech inputs and there is a code but it is impossible to get (medications) if meds are not in the profile. RN #21 said she offered Tylenol to Resident #19 when she first arrived as all residents have a standing order but she understood it was not equivalent to the [MEDICATION NAME]. RN #21 called NP around 10:43 p.m. and she called in the new order to the pharmacy for [MEDICATION NAME] 5/325 MG. RN #21 explained that she called the pharmacy to get the access code and to pull the [MEDICATION NAME] 5/325 MG. Around 11:00 p.m. RN #21 said she could not get the medication and that she tried again at 11:11 p.m. and said, I couldn't get the medication because it was not uploaded in the resident's profile. RN #21 called the pharmacy and NP but did not call the DON. RN #21 explained that around 11:53 p.m. the resident was frustrated and didn't want to wait any longer and asked to call 911. When asked if she would do anything differently, RN #21 stated, If there was something I could do I would, I didn't have anything else, it was an issue with the pharmacy. She added, Now we call the pharmacy and make sure we have the orders before the resident gets here. RN #21 confirmed that she was educated after this incident and attended an in-service on pain. On 12/1/16 at 9:30 a.m. the Clinical Educator was interviewed. She explained that the problem identified was not being able to handle uncontrolled pain quickly. Obtaining scripts and the transition from acute care to the facility would improve. The focus was explained to educate the RN directly involved as an isolated incident and then to educate all nursing staff. The unit manager met with RN #21 to discuss the process on 3/15/16. Documentation of the education was presented with RN #21 attending all in-services. The pain assessment in-service dates were 3/29/16 and 4/1/16 for all RNs and LPNs (Licensed Practical Nurse). The expectation is that nursing staff use resources, calling on-call staff management, DON or ADON. A night supervisor was hired in April and started in May to assist with any concerns. Conversations between the facility and the pharmacy staff occurred to improve the process. On May 18 and 19 a skills fair was conducted to include pain management for all nursing and CNA (Certified Nursing Assistant) staff. The QA/PI (Quality Assurance/Performance Improvement) Action Plan was presented by the clinical educator. The action plan was reviewed on 8/15/16 at the Quarterly meeting. Steps highlighted were presented to achieve past non-compliance. The following steps were taken by the facility: On 3/15/16, the day following the incident with Resident #19, nursing staff involved was educated by unit manager on how to properly assess for pain and communicate resident's needs immediately. Education was also provided on proper documentation. On 3/29/16 and 4/1/16 education provided to all nursing staff concerning non-pharmacological measures to control pain, verbal and non-verbal expressions of pain and proper documentation to reflect that pain has been addressed. Sign-in sheets reviewed. Audits were conducted: 1 chart per wing weekly with residents on PRN pain medications and 1 chart per unit reviewed weekly with residents on scheduled pain medications. Auditing for pain control and effectiveness with focus on pain scale. The audit completion date was 9/18/16. The dates for the Nursing Staff Meeting to focus and educate on the action plan were: 8/31/16, 9/1/16, 9/2/16, 9/7/16, 9/9/16, 9/14/16 and 10/5/16. The sign-in sheets were reviewed. Skills Fair for all nursing and CNA staff conducted on May 18 and 19. Sign-in sheets were reviewed. Ongoing scheduled meetings are held with the Pharmacy representatives to address availability of medications and the process for obtaining them. Results of audits will be reported at the QA meeting for trending. On 12/1/16 at 10:00 a.m. the unit manager RN #8 was interviewed. RN #8 confirmed that she educated RN #21 on 3/15/16 regarding the incident. RN #21 was instructed to call other staff management and to call the pharmacy directly when having access issues. RN #8 stated, I know we have improved in communication because we (management staff) have been called since this issue when narcotics are needed to be pulled and it was not in the profile. RN #8 also explained that the night supervisor is also available to assist. On 12/1/16 at 11:00 a.m. the Medical Director of the facility was interviewed. Administrative Staff #4 stated, Expectations when someone is in pain: assume high priority to be addressed. He added, Once a patient arrives the severity of pain should be addressed right then and there and for lesser levels of pain only 1 to 2 hours (should be addressed), urgency is placed with any circumstance. Finally, he identified that if staff at the facility don't have a script after hours, the on-call services are available to contact a physician or NP and he added, We usually talk to the pharmacy directly. On 12/1/16 at 11:30 a.m. a pharmacy representative (Others #21) was interviewed. Others #21 explained, There is a cut off (delivery) time for this facility at 5:00 p.m. any order received after 5:00 p.m. must be called into the pharmacy because the computer moves it to the next order time and it will not be delivered until next morning at 10:00 a.m. He also explained that the Pharmacy representative working on the night of 3/14/16 did not know this was an admission or a refill. The faxed order was received by the pharmacy at 8:14 p.m. for [MEDICATION NAME] 10/325 MG and placed into the system at 10:52 p.m. and verified by the pharmacy at 11:06 p.m. At 11:54 p.m. access code was given and authorization given to pull 2 5/325 MG. tablets. He explained further if 10/325 MG was checked on and it was not in the machine it would send a error message, Not in Stock and I honestly think this was user error, maybe inputting 10/325 instead of 5/325? On 3/15/16 Others #21 spoke with the facility staff and stated, We still don't know .the machine was working but we can't see what happened on our end .we just have history that the medication was there and the order was there and there was no errors recorded that day. Others #21 added, We (pharmacy) could have unlocked the cabinet remotely. Others #21 stated, Our system transmits immediately to the facility (name of automated medication system) and it would verify if the med is in the machine or not. Documentation was provided of the (name of automated medication system) log from the pharmacy's view and reviewed with Others #21. It was clear from the documentation that RN #21 made several attempts to access the medication but did not remove any medication. Others #21 encouraged facility to look at Policy 3.1 Routine Medication Orders. According to the Pharmacy Policy 3.1 Routine Medication Orders with a revision date of 8/7/12 section 2 titled New Orders: If the medication is needed before the next scheduled delivery time, call the pharmacy before submitting the order and be sure to state the exact date and time the medication is needed on the order and when calling the pharmacy. Pharmacy Policy 7.1 Acquisition of controlled Substances with a revision date of 10/1/11 reads, It is the nurse and the prescriber's responsibility to obtain the required prescription needed to meet the needs of the resident. According to the facility Resident Admission Policy with a revision date 1/09, one of the objectives of the admission policy is to, Reduce the fears and anxieties of the resident and family during the admission process. The facility Pain Assessment and Management Policy with a revision date of 9/10 documented: The Purpose: to help a resident attain or maintain his/her highest practicable level of well-being and to prevent or manage pain, to the extent possible the facility: a) Recognizes when the resident is experiencing pain . b) Evaluates the existing pain . c) Manages or prevents pain, consistent with the resident's goals . The facility administration was informed of the findings during a briefing on 12/1/16 at approximately 1:30 p.m. The facility did not present any further information about the findings. Complaint deficiency and Past non-compliance *[MEDICATION NAME] generic Hyrocodone [MEDICATION NAME]/[MEDICATION NAME] This combination medication is used to relieve moderate to severe pain. It contains an opioid (narcotic) pain reliever. Pain medications work best if they are used as the first signs of pain occur. If you wait until the pain has worsened, the medication may not work as well. (http;//webmd.com/drugs/2/drug-63/[MEDICATION NAME]-oral/details)

Based on observation, clinical record review, staff interview and facility document review, the facility staff failed to administer sliding scale insulin per physician order for [REDACTED].#24 and Resident #14. 1. Resident #24 was given [MEDICATION NAME] Insulin on 5 occasions including 4/11/13, 4/12/13, 4/13/13, 4/14/13 and 4/15/13 without an order. The resident experienced a change in condition, was sent to the hospital and diagnosed as having [DIAGNOSES REDACTED] (low blood sugar). 2. Resident # 14 did not receive 2 units Humalog insulin for an accu-check reading of 220 as expected by physician order on the morning of 9/10/13. Findings included: 1. Resident #24 was given [MEDICATION NAME] Insulin, a fast acting insulin, at 8:00 pm, on 5 occasions including 4/11/13, 4/12/13, 4/13/13, 4/14/13 and 4/15/13 without a physician order. Resident # 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident # 24's MDS (Minimum Data Set) assessment done as an admission review, with an ARD (Assessment Reference Date) of 4/22/13, Resident # 24 was a 15 of 15 on the Brief Interview for Mental Status (BIMS). Resident # 24 was coded as having Diabetes and [MEDICAL CONDITION]. Review of Resident # 24's clinical record revealed the resident had a change of condition noted at 10:30 pm on 4/15/13. Review of the resident's Blood Sugar flowsheet indicated that at 8:00 pm the resident's blood sugar had been 334 and the nurse had administered 8 units of [MEDICATION NAME] Insulin. Subsequent Blood Sugars were documented as: 10:30 pm - 21 10:40 pm - 18 10:45 pm - 24 10:55 pm - 47 Panic range for blood sugars are (less than 35 or greater than 243 when fasting) A Manual of Laboratory and Diagnostic Tests, 7th edition, Lippincott, Williams & Wilkins, 2004. Review of an SBAR Report (a report to the Physician for symptoms, signs and other changes of conditions) revealed that the resident's condition changed and at 10:30 pm the resident had a blood pressure of 243/127 and was described as unable to talk with "jerking body around in bed". The resident's Blood Sugar at that time was documented as 23 (documented as 21 on the flowsheet) . The report indicated Resident # 24 was transported to an Acute Care Facility to be seen in the emergency room . The resident returned to the facility at 3:30 am with a [DIAGNOSES REDACTED]. Review of Resident # 24's Physician Orders on 4/10/13 revealed the following orders: "Glucose Instructions : Q AC and QHS Sliding Scale Insulin: [MEDICATION NAME] subcutaneous with meals per sliding scale 3x (3 times) a day 150 - 200 2 units 201 - 250 4 units 251 - 300 6 units 301 - 350 8 units 351 - 400 10 units 401 - 450 12 units 451 - 500 14 units over 500 16 units and call MD" Review of Resident # 24 ' s MAR (Medication Administration Record) revealed an order dated 4/10/13 that read Insulin [MEDICATION NAME] 100 Units/ ml. Check blood sugar 3 times a day (before meals) * use per sliding scale and inject subq". Review of the Blood Sugar Flow Sheet revealed, in the space titled "Accu-check Order" the handwritten words "AC (before meals) and HS (bedtime)" In the space titled "Sliding Scale Order" the handwritten words listed the sliding scale (as above). Below and to the side of the sliding scale, a handwritten note stated "[MEDICATION NAME] 3 x (times) a day". The Flow Sheet revealed Resident # 24 had received the following doses of [MEDICATION NAME] Insulin at 8:00 pm each night:. 4/11/13 at 8:00 pm 8 units (Blood Sugar (BS) = 304) 4/12/13 at 8:00 pm 12 units (BS = 402) 4/13/13 at 8:00 pm 10 units (BS = 378) 4/14/13 at 8:00 pm 6 units (BS = 289) 4/15/13 at 8:00 pm 8 units (BS = 334) There was no physician order for [REDACTED]. According to Nursing 2014 Drug Handbook, page 748, [MEDICATION NAME] (insulin [MEDICATION NAME]) is given to control [MEDICAL CONDITION] in patients with diabetes. [MEDICATION NAME]is noted as a fast acting insulin and is given "5 to 10 minutes before the start of a meal". In an interview with the Director of Nursing on 9/19/13 at 10:20 am the DON stated that in review of Resident # 24's change of condition the Unit Manager had found the errors in administration. The DON stated they believed the way the order was written for "Accuchecks AC and HS with coverage only AC" was confusing on the Blood Sugar Flowsheet and was the cause of the errors. As a result the facility decided to stop using the flowsheet and use the MAR for documentation only. 2. Resident # 14 did not receive 2 units Humalog insulin for an accu-check reading of 220 as expected on the morning of 9/10/13. Resident # 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident # 14's last MDS (Minimum Data Set) Assessment, with an ARD (Assessment Reference Date) of 8/25/13 Resident # 14 was coded as 15 of 15 on the BIMS (Brief Interview of Mental Status). Resident # 14 was coded as having Diabetes and [MEDICAL CONDITION]. Review of Resident # 14's Medication Administration Record (MAR) revealed that on 9/10/13 Resident # 14 had an 8:30 am Blood Sugar of 220. Review of Resident # 14's admission orders [REDACTED]" dated 9/8/13. The admission orders [REDACTED]" dated 4/10/13. The Physician Order documented on the MAR dated 9/8/13 read "Humalog Inj 100u/ml for sliding scale": 150 - 199 1 unit 200 - 249 2 units 250 - 299 3 units 300 - 349 4 units 350 - 999 5 units The Director of Nursing and Corporate Quality staff verified on 9/19/13 at 10:30 am that the 2 Units of Humalog Insulin was not administered as expected.

Based on staff interview, clinical record review and facility document review, the facility staff failed to follow the physician orders [REDACTED]. On 11/1/13 the physician directed the staff to discontinue the administration of Pro-stat AWC for Resident #104. The staff failed to follow the orders and continued to administer the Pro-stat AWC from 11/1/13 through 11/6/13. It was discontinued after the error was identified by the surveyor. The findings include: Resident #104 is a [AGE] year old admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. According to the NPUAP (National Pressure Ulcer Advisory Panel) an unstageable/unclassified pressure ulcer presents as: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. The current MDS (Minimum Data Set) a significant change with an assessment reference date of 8/12/13 assessed the resident as scoring an 8 out of 15 on the Brief Interview for Mental Status (significant cognitive impairment). The resident was assessed as having an unstageable pressure ulcer. On 10/24/13 the physician ordered Pro-stat AWC 30 ml (milliliters) by mouth daily until the wound heals. Pro-Stat? is medical food intended for the dietary management for persons with wound/pressure ulcers, at risk for pressure ulcers, unintentional weight loss, or have low serum protein levels. According to manufacturers directions for use: The intake is to be determined by a health care professional and is dependent on age, body weight and medical condition. Administer orally or through feeding tube. Use under medical supervision. On 11/1/13 the physician wrote an order to discontinue the Pro-stat AWC (advanced wound care). Review of the medication administration record on 11/6/13 evidenced the staff failed to discontinue the Pro-Stat. The nursing staff initialed the resident had received a daily dose at 9:30 A.M., from 11/1/13 through 11/6/13. On 11/6/13 at 1:45 P.M., the discrepancy was shared with the unit manager. The unit manager reviewed the physician order [REDACTED]. She then took the MAR and highlighted in yellow the Pro-stat order entry stating, "It's discontinued now". The unit manager indicated the discontinue order had also been reviewed by the night shift nurse during the 24 hour chart check the night of 11/1/13 as evidenced by the nurses initials. Twenty four (24) hour chart checks are a safeguard to ensure all physician orders [REDACTED]. The unit manager was asked why the Pro-stat was discontinued by the physician and stated ,"She (Resident #104) didn't like it". Review of the facility's policy Transcribing physician's orders [REDACTED]. D. Precautions Transcribing For Orders: 6. Record the orders in the required areas, such as MAR (medication administration record), TAR (treatment administration record), etc. Be certain to include date. 8. Make very certain that all orders have been carried out and recorded in the proper record. 9. Each order should be checked off on the physician's orders [REDACTED]. 11. The nurse must examine all resident's charts for new orders in their assignment every shift.

Based on observation, clinical record review, staff interview, and facility document review, the the facility staff failed to prevent a significant medication error for Resident # 24, 1 of 24 residents in the survey sample. Resident # 24 received 5 doses of fast acting [MEDICATION NAME] Insulin at 8:00 pm from 4/11/13 through 4/15/13 for coverage of blood sugar without an order. The resident was transferred to the emergency department of an acute care facility on 4/15/13 with [DIAGNOSES REDACTED] (low blood sugar). Findings included: Resident # 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident # 24's MDS (Minimum Data Set) assessment done as an admission review, with an ARD (Assessment Reference Date) of 4/22/13, Resident # 24 was a 15 of 15 on the Brief Interview for Mental Status (BIMS). Resident # 24 was coded as having Diabetes and [MEDICAL CONDITION]. Review of Resident # 24's clinical record revealed the resident had a change of condition noted at 10:30 pm on 4/15/13. Review of the resident's Blood Sugar flowsheet indicated at 8:00 pm the resident's blood sugar had been 334 and the nurse had administered 8 units of [MEDICATION NAME] Insulin.Subsequent Blood Sugars were documented as: 10:30 pm - 21 10:40 pm - 18 10:45 pm - 24 10:55 pm - 47 Panic range for blood sugars are (less than 35 or greater than 243 when fasting) A Manual of Laboratory and Diagnostic Tests, 7th edition, Lippincott, Williams & Wilkins, 2004. Review of an SBAR Report (a report to the Physician for symptoms, signs and other changes of conditions) revealed that the resident's condition changed and at 10:30 pm the resident had a blood pressure of 243/127 and was described as unable to talk with "jerking body around in bed". The resident's Blood Sugar at that time was documented as 23 (documented as 21 on the flowsheet). The report indicated Resident # 24 was transported to an Acute Care Facility to be seen in the emergency room . The resident returned to the facility at 3:30 am with a [DIAGNOSES REDACTED]. Review of Resident # 24's Physician order [REDACTED]. "Glucose Instructions: Q AC and QHS Sliding Scale Insulin: [MEDICATION NAME] subcutaneous with meals per sliding scale 3x (times) a day 150 - 200 2 units 201 - 250 4 units 251 - 300 6 units 301 - 350 8 units 351 - 400 10 units 401 - 450 12 units 451 - 500 14 units over 500 16 units and call MD" Review of Resident # 24 ' s MAR (Medication Administration Record) revealed an order dated 4/10/13 that read Insulin [MEDICATION NAME] 100 Units/ ml. Check blood sugar 3 times a day (before meals) * use per sliding scale and inject subq". Review of the Blood Sugar Flow Sheet revealed, in the space titled "Accucheck Order" the handwritten words "AC (before meals) and HS (bedtime)" In the space titled "Sliding Scale Order" the handwritten words listed the sliding scale as above. Below and to the side of the sliding scale a handwritten note stated "[MEDICATION NAME] 3 x (times) a day". The Flow Sheet revealed Resident # 24 had received the following doses of [MEDICATION NAME] Insulin at 8:00 pm each night without a physician's orders [REDACTED]. 4/11/13 at 8:00 pm 8 units (for Blood Sugar (BS) = 304) 4/12/13 at 8:00 pm 12 units (for BS = 402) 4/13/13 at 8:00 pm 10 units (for BS = 378) 4/14/13 at 8:00 pm 6 units (BS = 289) 4/15/13 at 8:00 pm 8 units (334) According to Nursing 2014 Drug Handbook, page 748, [MEDICATION NAME] (insulin [MEDICATION NAME]) is given to control [MEDICAL CONDITION] in patients with diabetes. [MEDICATION NAME]is noted as fast acting insulin and is given "5 to 10 minutes before the start of a meal". In an interview with the Director of Nursing on 9/19/13 at 10:20 am the DON stated that in review of Resident # 24's change of condition the Unit Manager had found the errors in administration. The DON stated they believed the way the order was written for "Accuchecks AC and HS with coverage only AC" was confusing on the Blood Sugar Flowsheet and was the cause of the errors. As a result the facility decided to stop using the flowsheet and use the MAR for documentation only. Resident # 24 received 5 doses of fast acting [MEDICATION NAME] Insulin at 8:00 pm each night from 4/11/13 through 4/15/13 for coverage of blood sugar without an order.

Based on a complaint investigation, clinical record review, staff and family interviews and facility documentation, the facility staff failed to implement interventions to include the necessary assistance, positioning and assistive devices to prevent falls for 1 of 5 residents in the survey sample, Resident #1. Resident #1 sustained multiple fractures from two separate falls out of bed. The findings included: Resident #1 was originally admitted to the nursing facility on 7/27/99 with [DIAGNOSES REDACTED]. The resident fell out of bed with injuries on 8/19/12, and was most recently readmitted to the nursing facility on 12/10/12 after a second fall from the bed with injuries on 12/8/12. The resident was under hospice care from 9/13/12 because of end stage dementia. The Minimum Data Set (MDS) assessment dated [DATE] was a significant change and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 7 (severe impairment in the cognitive skills for daily decision making). She was not coded with any behavioral or mood problems to include resisting care (Activities of Daily Living). The resident was assessed to require extensive assistance of one staff for bed mobility, dressing, toilet use, personal hygiene and bathing. She was coded to need extensive assistance of two staff for transfers. She did not have any limitation in range of motion of upper or lower extremities, but did not walk in room or corridor. She was assessed as not steady with surface to surface transfers without assistance and normally used a wheelchair for mobility. The most recent quarterly MDS dated [DATE] coded the resident as totally dependent on the support of two staff for bathing. The care plan dated 7/23/12 indicated the resident had no or limited potential for change in Activities of Daily Living (ADL) performance and required extensive to total assistance with ADLs. One of the goals for the resident was she would not experience adverse outcomes from requiring extensive assistance with or being dependent in ADLs. Some of the interventions to accomplish this goal included keep assistive devices within easy access for resident, i.e., 1/2 side rails, wheelchair, report changes to the nurse, offer instruction in a clear concise manner, provide sufficient time for resident to complete the task. The care plan dated 1/24/12 and reviewed on 9/30/12 with no changes, identified the resident was at risk for falls related to short term memory loss, requiring staff assistance for transfers, impaired sensation and unstable fluctuating health (diabetes and hypertension). The goal set for the resident was she would not experience a fall. Some of the interventions to accomplish this goal included, keep call bell within reach, report changes in health condition and fall precautions. The care plan dated 8/20/12 indentified a fall and indicated, "rolled out of bed-has an air mattress, fracture left hip". The 12/8/12 fall "with fracture to right hip (12/10/12)" was also noted on this care plan. Some of the interventions included removal of air mattress on 8/20/12 and Occupational evaluation for use a bed wedge. A telephone order for the wedge when turning with Geomat (standard mattress) was written on 8/22/12. An intervention for the bolsters to bed was dated 12/10/12, as well as low bed and mat at bedside implemented on 12/12/12. According to the care plan for skin integrity the Geomat was discontinued on 8/10/12 and alternating air mattress was implemented; a low air loss mattress was implemented with bolsters (perimeter air mattress) on 9/12/12. Resident # 1's Fall Risk Assessments dated 7/9/12, 8/19/12, 9/17/12 and 12/8/12 indicated the resident was at high risk for falls The following observations were made of Resident #1: On 2/12/13 at approximately 2:00 PM, Resident #1 was observed in bed and awake. She had bilateral air waffle boots in place that extended from her knees to feet with toes exposed. Both legs were completely turned outward. The resident was on a low air low mattress with a 4 inch defined perimeter mattress cover. The foam wedge was not in place, but across the room on a chair. The right side of the bed was against the wall. The bed was in low position, close to the floor with a mat on the floor to the left of the bed. She was not able to hold a conversation, but responded with short appropriate statements ("fine," "okay," "alright baby"). According to manufacturer's information on the defined perimeter mattress cover dated 2011, this specific cover offers a low intervention solution to bed safety issues. The wedge-shaped foam sections line the perimeter of the cover and help provide a gentle reminder to those lying in the bed of the location of the mattress edges and help provide a less restrictive environment that side rails. There are openings in the mid section for easy patient entry and exit. On 2/12/13 at 4:50 PM, the resident was again observed in bed in the same position on her back. Certified Nursing Assistant (CNA #1) was at the bedside during this observation and stated she was with the resident at the time of the 8/19/12 fall. She pointed to the bed and said the bed was not against the wall at the time and she was able to access the resident on both sides of the bed. She stated she was giving the resident a bath and she on an air mattress that was straight across without the scoop sides. She stated the 1/2 side rails on both sides were up, but the resident did not use them or hold on to them to aid during turning and repositioning or stop her from falling out of bed. She stated the side rails mainly kept the air mattress in place that was higher than the side rails. CNA #1 continued during the interview to say, "The bed was in the highest position so I could bath the resident better and not hurt my back. I turned the resident on her left side to wash her back and when I went to wring out my wash cloth she did not fall out of bed, she just rolled out of bed onto the floor. What was I supposed to do, I could not hold onto her with one hand and wring the wash cloth out with the other hand and she could not follow instructions to hold onto the side rail. I needed to use both hands to wring out the wash cloth; it was just an issue with her rolling out of the bed. To this day, I was not told by anyone I did anything wrong." An interview was conducted with the Registered Nurse (RN #1), on 2/12/13 at 4:00 PM, who assessed the resident after the 8/19/12. She stated she understood the resident was in bed at the time of the fall and the CNA turned to wring out the wash cloth and the resident rolled off the bed onto the floor. The RN said she was called to the room by CNA #1 to come quickly and upon doing so, found Resident #1 on the floor to the left side of the bed. She stated the bed was in the high position and the resident was on an air mattress of some type. She said the CNA was in the process of bathing her at the time of the fall. She said the resident was total care, non-ambulatory and did not have the ability to stop herself from falling and was "dead weight". RN #1 stated, "I recalled a huge lump on her head and we sent her out 911. I did not notice anything else at the time, but that large lump. The next day I came on for my shift, I noticed swelling from left knee to the ankle and I notified the physician." The nurse's notes indicated the physician ordered a mobile Doppler study and x-ray of the left leg on 8/21/12 because of continued edema, resident complaints of pain. The nurse's notes further indicated the results were reviewed by the attending physician and revealed acute fractures of the left tibia (oblique) and left femur (impacted). The resident was sent to the local Emergency Department (ED) on 8/21/12 at 6:00 PM. She returned on 8/22/12 at 12:20 AM with left leg in a cast and Tylenol 325 milligrams (mg) 2 tabs as needed for pain/fever per standing order. Morphine Sulfate (MS) solution 10 mg/5 milliliters (ml), to give 2.5 ml (5 mg) was ordered sublingually (sl) twice a day as needed for pain. The cast was removed on 10/8/12. On 12/8/12 at 5:20 PM, the nurse's notes indicated the resident was observed on the floor on her right side and on her head. The notes indicated the resident stated her "right leg hurt". The resident was sent to the local ED via 911. The nurse's note dated 12/8/12 at 9:45 PM indicated the resident was being transported another facility for evaluation by an orthopedic surgeon. Resident #1 returned to the nursing facility on 12/10/12 with a full right leg immobilizer, to be kept on unless bathing. On 12/12/12 the nurse's notes indicated the resident was grimacing and flailing her arms and refusing to eat. physician's orders [REDACTED]. On 12/13/12 MS 2.5 ml sl was again increased to every 4 hours for leg pain, as well as Ativan 1 mg every 4 hours for agitation. On 2/12/13 at 3:30 PM, an interview was conducted with the CNA (CNA #2) that found the resident after the incident on 12/8/12. She and this writer went to the resident's beside for a clear description of how the resident was found on that day. She stated she came into the resident's room to pick up the evening meal tray on 12/8/12 at around 5:30 PM and found the resident's upper body hanging out of the right side of the bed upside down on her head with her legs still in the bed. She said the bed was not in the lowest position, there was no mat on the floor and she did not remember seeing a perimeter mattress, but remembered the air mattress was higher than the side rail and not raised on the edges. She stated, "She was always poorly positioned and had a tendency to lean to the side. There were no pillows or wedge cushions on the bed when I found her." She stated the resident was not able to use her call bell. On 2/14/13 at approximately 2:00 PM, an interview was conducted with the Licensed Practical Nurse (LPN #1) that assessed the resident after the incident on 12/8/12. She stated, "The aide asked me to go into the room because the resident was on the floor. Her upper body and head and was on the floor and her legs were entwined in the bed covers. I straightened her body and recognized her right leg was externally rotated out of normal alignment and the resident said, 'My leg hurts'. She was also grimacing as though she was in pain. I have taken care of her before and her legs were usually in a normal straight position". LPN #1 continued to say she was on a black air mattress, could not remember if they were curved on the edges, but appeared straight across a little above the side rails. She stated the resident did not use the side rails and if she was not positioned well, once she started leaning or falling she would "keep on going". She stated the resident was unable to use a call bell or understand how to use it. She said the resident was sent via 911 to the local ED and then to another facility. She referred to her nurse's notes and stated the local hospital called the facility to report a right distal femur fracture and she was being transported to see an orthopedic surgeon. LPN #1 also readmitted the resident on 12/10/12 and stated she had a full length leg immobilizer in place. The hospital Discharge Summary dated 12/10/12 indicated the reason for admission was right distal femur fracture status [REDACTED]. A right knee immobilizer was ordered. The Hospice CNA #3 was interviewed at the resident's bedside on 2/13/13 at 12:45 PM. She stated she had been her major care giver for at least 2 months and did not get her out of bed due to leg fractures. She said she was the one who turned the right side of her bed to the wall after she found out about the last fall. The resident was observed positioned on her left side with the wedge at the right side of her back, as well as a pillow under the left shoulder blade. The bed was observed in the low position and the mat on the floor. CNA #3 stated she mainly provided all ADL care to include bathing and feeding. She stated, "Even though she has this mattress, you still have to position her correctly because the curved edges aren't high and they are very soft; she will lean over and she cannot stop a fall or hold on to anything. You have to block her in with pillows and the wedge." CNA #3 stated the resident could not use a call bell. The Hospice Nurse RN #2 was interviewed on 2/13/13 at 1:00 PM. She stated the resident was initially on hospice 9/13/12 due to failure the thrive and end stage dementia, and re-instated on 12/14/12. RN#2 stated besides nutritional concerns, pain management was one of their main focus areas and on 1/21/13 the Nurse Practitioner ordered a Fentanyl (narcotic pain medication released through the skin) patch 12.5 mcg/hour to change every 72 hours due to pain from the falls. She stated, "Because of her advanced age ([AGE] years old) and the complications of her fractures, she was not a candidate for surgery. So, we need to keep her as comfortable as we can." The POA was interviewed on 2/13/13 at 3:00 PM. She stated prior to taking over as POA on 12/18/12 she visited with the previous POA and another family member on a consistent basis. She stated she usually visited in the evening 3 times or more a week and did not consistently see a wedge in place to position the resident. She also stated she was told by the DON the low bed and mat was ordered on [DATE], but it was not until after it was addressed during a care plan meeting on 12/14/12 that she noticed the mat and the low bed. She stated she asked the DON about assistance needs at that time and was told, 'There was not policy for that.' She stated she just noticed the bed against the wall about two weeks ago, but did not know who initiated the change. According to the POA, she and another family member expressed their concerns during the meeting about pain assessments and that the resident appeared more uncomfortable on 12/13/12 and 12/14/12. The POA stated based on their concerns, a nurse called the physician to further address the resident's pain. On 2/14/13 at 10:00 AM, an interview was conducted with the Director of Nursing, the Assistant Director of Nursing (ADON) and the Corporate Nurse. The DON stated she felt the air mattress was the reason for the resident's first fall, and it was discontinued on 8/20/12 with the resident back on the standard Geomat mattress and wedge to keep the resident off her back to prevent pressure areas. She said the resident was placed back on the low air loss mattress to ensure adequate pressure reduction and pressure sore prevention with a perimeter cover on 9/12/12. She said the Power of Attorney (POA) had met with her on 12/14/12 about her concerns surrounding the falls. She stated the low bed with the mat and increase in staff assistance for bathing was implemented after the second fall on 12/12/12. The resident had not not been assessed for side rail usage. The DON and Corporate Nurse stated there was an order for [REDACTED]. The most recent X-rays on 2/5/13 of the left and right femur with lateral views revealed no change in the disposition of fractures. The Activities Coordinator was interviewed on 2/14/13 at 2:15 PM. She stated before the falls and she was relegated to bed,the resident loved to sit at the nurse's station and visit everyone that went by, as well as attend church services, socials to include parties and holiday gatherings. She stated, "This would be a day she would love because we have elaborately decorated for Valentines day." On 2/15/13 at 10:15 AM, the Director of Environmental Services measured the height of the bed in it's highest position with an alternating air mattress as 40 inches from top of mattress to the floor. He measured the bed in it's highest position with a low air loss mattress and perimeter cover as 36 inches from top of mattress to the floor. The low bed mattress and perimeter measured 15 inches from top of mattress to top of the three inch thick floor mat (composed of foam with urethane cover). On 2/15/13 at 2:00 PM, an interview was conducted with the Administrator, the DON, ADON and the Corporate Nurse, as well as the facility's Unit Managers and the Staff Development Coordinator. Upon review of Resident #1's falls, the DON stated in reference to the fall of 8/19/12, "When I look back at the situation, the aide should have gotten the help she needed to support the resident during the bath." The Corporate Nurse stated, "I see exactly what the problems were." There was no explanation for why the low bed and mat was not initiated until after the second fall, which may have protected the resident from subsequent injury related to the second fall of 12/8/12. The facility's policy and procedure entitled Falls Prevention and Management dated 9/12 indicated it was the facility's policy's purpose to identify the risk of falls and using a interdisciplinary approach to fall management and prevention, implement a fall prevention plan of care. To prevent fall and/or further injury by follow-up needs, focus on the under lying cause and implementation of interventions that focus on that cause: teaching, adjusting environment, assitive/adaptive devices, staff monitoring and responsiveness, reviewing and monitoring plan of care. The facility's policy further indicated when the resident is found on the floor, the event must be investigated as a fall. Rolling out of bed or off mattress, even if low to the floor, going from one surface to a lower surface is a fall. Note the resident's positioning, environment, and activities involved in prior to the fall to assist in the investigation of causative factors and implementation of appropriate interventions. The nurse will take any immediate measures necessary to prevent a recurrence of a fall. If a resident scores an 8 or above consider (among many other interventions) mats on the floor, a low bed and positioning devices (not a restraint). COMPLAINT DEFICIENCY